MetroWest Medical Center is the largest community health care system between Worcester and Boston. MetroWest Medical Center is committed to providing high quality, comprehensive care, at a location close to home. The 307-bed regional healthcare system includes Framingham Union Hospital, Leonard Morse Hospital in Natick and the MetroWest Wellness Center. MetroWest Medical Center has been named to the 2019 Americaï¿½s 100 Best Hospitals List by Healthgrades.
GENERAL SUMMARY: The individual in this position is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patientï¿½s resources and right to self-determination. The individual in this position has overall responsibility to assess the patient for transition needs including identifying and assessing patients at risk for readmission. Conducts complex psycho-social assessment and interventions to promote timely throughput, safe discharge and prevent avoidable readmissions. This position integrates national standards for case management scope of services including:
ï¿½Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
ï¿½Care Coordination by demonstrating throughput efficiency while assuring care is sequenced and provided at the appropriate level of care
ï¿½Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
ï¿½Education provided to physicians, patients, families and caregivers
ï¿½Participates in planning the social work component required in selected hospital programs
ï¿½Provides in-service education for staff
ï¿½Collaborate with community providers to develop educational resources appropriate for staff and patients/patient representatives
This individualï¿½s responsibility will include the following activities: a) complex psycho-social transition planning assessment and reassessment and intervention, b) assistance with adoptions, abuse and neglect cases, including assessment, intervention and referral as appropriate to local, state and /or federal agencies, c) care coordination, d) implementation or oversight of implementation of the transition plan, e) leading and/or facilitating multi-disciplinary patient care conferences including Complex Case Review, f) making appropriate referrals to other departments, g ) communicating with patients and families about the plan of care, h) collaborating with physicians, office staff and ancillary departments, i) assuring patient education is completed to support post-acute needs , j) timely, complete and concise documentation in Tenet Case Management documentation system, k ) maintenance of accurate patient demographic and insurance information, l) and other duties as assigned.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
ï¿½Completes comprehensive assessment within 24 hours of patient admission to identify and document the anticipated transition plan for patients
ï¿½Integrates key elements of patient assessment, patient preference & choice and available resources to develop and implement a successful transition plan
ï¿½Completes Complex/Psycho-social assessment and plan for patients identified as high risk for readmission.
ï¿½Provides psycho-social assessment and intervention for patients identified with needs including behavioral health, lack of support systems, financial barriers, end of life, and/or medication adherence.
ï¿½May delegate the implementation of the transition plan to LVN/LPN or Assistant staff and follows up to ensure the transition plan is completed timely and accurately
ï¿½Ensures all elements of the transition plan are implemented and communicated to the healthcare team, patient/family and post-acute providers
ï¿½Provides information to patients to make informed choices per Tenet policy
ï¿½Completes Final Discharge Disposition Form for Medicare beneficiaries per Tenet policy
ï¿½Completes timely, complete and accurate documentation in the Tenet Case Management documentation system to communicating information to the care team and provide documents needed in the patient record
(40% daily, essential)
ï¿½Screens patients for factors that may affect the progression of care and intervenes as needed to promote timely and appropriate throughput
ï¿½Conducts assessments and stratifies patients at risk for readmission or in need of Case Management services
ï¿½Assists with adoption/abuse/neglect cases and reporting of appropriate cases to local, state and/or federal agencies
ï¿½Ensures the plan of care is consistent with patient preference & choice and available resources
ï¿½Ensures patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of care
ï¿½Effectively collaborates with physicians, nurses, ancillary staff, payors, patients and families to achieve optimal outcomes
(40% daily, essential)
ï¿½Ensures and provides education to patients, physicians and the healthcare team relevant to the safe and timely patient transition
ï¿½Provides patient and healthcare team education regarding resources and benefits available to the patient along with the economic impact of care options
ï¿½Ensures that education has been provided to the patient/family/caregiver by the healthcare team prior to discharge
(10% daily, essential)
ï¿½Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services
ï¿½Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and Tenet policies
ï¿½Operates within the Social Work scope of practice as defined by state licensing regulations
(10% daily, essential)
5.Complex Patient Management
ï¿½Completes quality and accurate Adult Transition Evaluations
ï¿½Completes accurate risk assessments and follow up as coach with other colleagues
ï¿½Starts discharge planning and referrals within 1-2 days of admission and escalate any barriers to care to DCM
ï¿½Schedules family/patient conferences with physicians, other disciplines at least weekly
ï¿½Assist in resolving difficult issues early for example - potential legal and ethical needs or complex medical concerns align with DCM
KNOWLEDGE, EXPERIENCE AND OTHER JOB REQUIREMENTS:
ï¿½Required qualifications include Master in Social Work (MSW).
ï¿½Accredited Case Manager (ACM) preferred.
ï¿½Minimum of two years acute hospital experience preferred.
ï¿½Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to lead and coordinate activities of a diverse group of people in a fast paced environment, critical thinking and problem solving skills and computer literacy.
Job: Laboratory and Clinical Technicians
Primary Location: Framingham, Massachusetts
Facility: MetroWest Framingham Union Hospital
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Internal Number: 2005029359
About MetroWest Framingham Union Hospital
“Tenet Healthcare Corporation is a diversified healthcare services company with 115,000 employees united around a common mission: to help people live happier, healthier lives. Through its subsidiaries, partnerships and joint ventures, including United Surgical Partners International, the Company operates general acute care and specialty hospitals, ambulatory surgery centers, urgent care centers and other outpatient facilities. Tenet's Conifer Health Solutions subsidiary provides technology-enabled performance improvement and health management solutions to hospitals, health systems, integrated delivery networks, physician groups, self-insured organizations and health plans.