Care Transition Liaison

Company/Location

Tufts Medicine Care at Home

Reports to

Director of Referral Management and Transitions of Care

Location: Lowell General- Main Campus

Hours: Monday-Friday (Days/Flexible) 9-5 or 10-6

Summary/Objective

The Home Care Liaison is responsible for following high risk patients that are referred by Careport to TMCAH from Lowell General Hospital and ensuring their transition to the home environment, which involves post hospitalization follow up. The Home Care Liaison works to thoroughly identify the needs of referral sources and referred patients, demonstrating a clear understanding of how referral sources make decisions and identifying decision-makers. Collaborating in a cross functional environment, assists with programs and protocols that provide for the effective transition of the patient and the delivery of improved home health care services, including performing complete and thorough pre-intake screens as appropriate.

As a key member of the health care team, the Home Care Liaison must interact courteously and effectively with patients and their families, as well as with co-workers from all Agency departments, community resources, and with patients' physicians. The Home Care Liaison carries out their responsibilities consistent with Agency policies, mission, and vision.

Essential Functions

• Coordinate home care for high-risk patients in the in-patient setting, collaborating with case managers, patient population nurses and TMCaH.
• Compassionate conversations with patients/families regarding services offered in the home environment.
• Conducts a full needs assessment.
• Responds to all referrals and inquiries promptly.
• Notifies the appropriate clinical team of impending admission and any pertinent information.
• Upon discharge, continues follow-up for a total of 14 days.
• Follow up of phone calls to the patients are scripted and focus on in-hospitalization assessment to identify any clinical changes to prevent a re-hospitalization.
• Post hospitalization documentation with nightly report sent to multiple clinical departments Informs physicians, hospital personnel, patients, families, and other interested groups about available services.
• Collaborates with physicians, case managers and managed care case managers.
• Determines appropriateness for home health services or hospice care.
• Provides information about specific agency programs and services.
• Discusses home health services or hospice options with the physicians, nurses, patients, and families.
• Assists with the coordination and establishment of a transitional care plan for home health services and hospice.
• Facilitates the provision of appropriate services; Infusion Therapy, tele health, etc.

Competencies:

Responsible- Takes pride in all work and seeks to perform with excellence. Is dependable and follows through on commitments. Conducts themselves in a professional manner and leads by example.

Innovative- Creative and innovative in working through challenges. Embraces change and understands it is necessary to thrive. Is solution-oriented and seeks ways to improve quality and service.

Supportive- Warm, approachable and easy to work with. Expresses appreciation and encouragement to colleagues, clients and patients. Goes beyond normal job responsibilities to help others succeed.

Enthusiastic- Brings passion, energy and optimism to the workplace. Speaks well of colleagues and the organization. Possesses a can-do attitude and looks at the upside of issues.

Humble- Respects differences and understands that diversity makes us stronger. Shares credit and admits mistakes. Leaves ego at the door and understands that we need each other to be successful.

Integrity- Acts in the best interest of our patients and organization. Is honest in all interactions. Does the right thing for the right reason.

Required Education and Experience

• Active RN licensure in Massachusetts and New Hampshire
• Minimum 2 years of relevant clinical experience.
• Home care and /or population health desired.
• Ability to read/write and communicate in English.
• Excellent interpersonal skills.
• Ability to function well in very busy situations.
• Responsible and reliable.
• Good organization skills.

What we Offer:

• Benefits effective day 1
• Competitive salaries
• Generous Sign on Bonus
• Dental and Vision Insurance

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any t

Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford, Care at Home - an expansive home care network, and large integrated physician network. We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine. Tufts Medicine does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation by emailing us at careers@tuftsmedicine.org.