Hospital to Home Transition Coordinator

Hospital To Home Transition Coordinator

The Hospital to Home Transition Coordinator is responsible for working with Medicaid clients who are transitioning from an acute care setting to a community setting, working with health care providers, such as hospital staff, home health care organizations, social service organizations to facilitate transitions. The Hospital to Home Transition Coordinator will also work with acute care facilities to educate staff on how to identify and refer eligible individuals to the Hospital to Home (H2H) program.

Receives general supervision from the Medicaid Waiver Coordinator. Supervisor sets the overall objectives and employee and supervisor, in consultation, develop the deadlines, projects, and work to be done; employee is responsible for planning and carrying out the assignment; and work is reviewed only from an overall standpoint.

Responsibilities and Duties:

• Receives incoming referrals from hospital staff or ADRC for completeness and schedules time to assess the individual for transition. Establishes FamCare record for client and documents all activity and narratives within client record.
• Verifies eligibility and searches for current or past enrollment for waiver services through available databases.
• Works with hospital staff to gather information on potential program eligibility by collecting needed information and documentation.
• Makes face to face contact with patient/client, power of attorney, or guardian unless virtual is necessitated by restrictions. Conducts a prescreen utilizing the prescreening tool and confirms information, collects missing documents and discusses DME.
• Submits summary of case and other prescreening information to ADSS H2H Nurse reviewer for viability.
• Refers individuals that cannot be served in a timely manner or are found to be ineligible at this stage to ADRC, based on client desires.
• Works with discharge planning staff to coordinate home health referrals, medications, and other needs for transition covered items.
• As necessary, completes an ACT Waiver Services Authorization Request (SAR) for home essentials, home modifications, assistive technology, DME, or PERS to support individual health, welfare, and safety. Any ACT quotes, or prescriptions are uploaded into AIMS.
• Approved SARs require purchases be made and delivery arranged or transition items.
• Creates and submits purchase orders, payment requests and maintains receipts for submission to accounting for ADSS reimbursement process.
• Maintains contact with hospital staff and client until client is safely discharged to home. Prescreening tool in FamCare is closed with transition outcome documented. Client is now supported by assigned case manager.
• Establishes and maintains effective relationships with acute care facilities, rehabilitation centers and facilities and other healthcare services providers.
• Educates facility case managers, discharge planners, and other staff on program benefits, the identification of potential candidates, and the agency referral process.
• Educates health care providers, home health agencies and other services providers to keep their patients/clients informed and aware of the South Alabama Regional Planning Commission (SARPC) Hospital to Home program.
• Monitors service area landscape for new acute care facilities, rehabilitation centers or facilities, and similar organizations; establishes relationships with these new facilities and service providers.
• Tracks and documents number of outreach activities and referrals generated.
• Other job duties as assigned.

Knowledge, Skills, and Abilities Required:

• Knowledge of social work programs and processes preferred
• Knowledge of community resources and support network available to clientele served.
• Excellent communication skills, both orally and written.
• Excellent organizational and time management skills.
• Ability to relate to the elderly and their unique problems. Working knowledge of medical and hospital terminology, basic health needs, and common medical conditions of the aging population.
• Knowledge and ability to operate office equipment including telephone, copy machine, fax machine, computer, and calculator.
• Knowledge and ability to do basic arithmetic.
• Ability to read and interpret guidelines and regulations and apply them to the job.
• Bachelor's Degree from an accredited four-year college or university in Social Work, Behavioral Sciences, Psychology, Geriatric Studies, or related field. At least one (1) year of case management experience.
• A valid driver's license and a good driving record.

Work Conditions:

The work is sedentary. Typically, the employee may sit comfortably to do the work. However, there may be some walking; standing; bending; carrying of light items such as papers, books, small parts; driving an automobile, etc. No special physical demands are required to perform the work.

Supervisory Responsibilities:

None