Overview

DUTIES AND RESPONSIBILITIES:

JASA’s Care Transitions Specialist (CTS) will coordinate, screen and facilitate the provision of home and community based support services to improve hospital to home care transitions to avoid preventable 30-day readmissions. The CTS, an International Medical Graduate, must be bilingual (English/Spanish) and have the capacity to work across home, community and clinical settings, including in-hospital.

The CTS must be available to meet patients/caregivers and the hospital discharge team on-site to enable a warm hand-off. The Care Transitions Specialist also will conduct in-home assessments with the following objectives:

  • Identify home-based issues that may be linked to readmission risk
  • Provide direct services and referrals to support stable home based functioning, focusing on:
  • Medication/DME (other supplies): Ensure patient has medication, supplies and equipment and understands prescribed use
  • Patient Education: Ensure patient is aware of their health conditions and how to manage them, and understands red flags and health risks
  • Health Care Provider Communication and Coordination: Ensure patient has a primary care provider (PCP), update PCP on patient status, assist patients with follow up appointments
  • Screen for and identify social and mental health needs of patients and provide closed-loop referrals

This position will be responsible for:

  • The provision of in-hospital (or other clinical setting and, in-home assessments of the social and emotional needs of the older adult client and their family, utilizing prescribed standardized assessment instruments;
  • The provision of a full range of social services for the older adult client(s) and family, including:Education and support to improve disease self-management and prevent avoidable hospital use
  • Screening of client eligibility, application for, and advocacy in securing benefits and entitlements
  • The arrangement for direct provision of services such as transportation, homecare services, meals on wheels/nutrition services, public assistance, Medicare, Medicaid, emergency cash relief, legal aid, protective services, medical and psychiatric examination and therapy, housing, etc.
  • Referral, development of relationships and cooperative work with other community agencies, to meet the needs of clients
  • Informing supervisors of situations of crisis or circumstances where the worker requires further guidance.
  • Participating in training and team meetings.
  • Collecting and inputting patient data into JASA’s Electronic Health Record system and assisting with analytics, reports and statistics, utilizing computers.
  • Performs such other duties as assigned.

 

QUALIFICATIONS:

  • International Medical Graduate or equivalent.
  • Graduate of an Accredited College or University with B.A./B.S. degree
  • Good writing/record keeping skills.
  • Ability to read, write, speak, understand English.
  • Ability to read, write, speak, understand Spanish.
  • Must be computer literate, including ability to learn and use program-specific software.
  • Ability to travel to clients’ homes using mass transit and to negotiate any steps and barriers in clients’ residences.
  • Hospital discharge planning or other health care experience preferred.
  • Understanding and appreciation of the roles of race, religion, ethnicity, sexual preference, and individual values as they relate to serving clients and families.

Terrific professional opportunity for International Medical Graduates!

SUBJECT TO REVIEW FOR PURPOSES OF ADAAA

JASA is committed to Equal Opportunity Employment

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