Home And Community Based Services (Hcbs) Hospital Liaison

AgeSpan
Formerly Elder Services of the Merrimack Valley/North Shore
About Us: Since 1974 our agency has strived towards supporting an individual's desire to make their own decisions, secure their independence and remain living independently in the community. We are proud of our employees who make this possible every day. Our agency is a thought-leader, a nationally known generator of new ideas, because it welcomes creativity, your ideas. It is an outstanding place to work stimulating, friendly, collaborative. We offer competitive salaries, generous vacation time, and an excellent work/life balance. We value diversity and encourage career growth. If you have a passion for improving the lives of the elderly community and enjoy working in a diverse team driven by its mission, you've found the right place!
At AgeSpan, You'll Find a Work Environment That Combines

• A refreshing culture that is supportive, collaborative, and encouraging of diverse perspectives and backgrounds.
• A focus on innovation with a team recognized for developing and implementing innovative programs and novel solutions.
• A satisfying balance between your work and personal life, including a flexible workplace, generous paid time off, and wellness programs.
• Encouragement of your development through opportunities to get involved, use your voice, and gain new knowledge and skills.

Depending on your role and your hours, we offer

• Free parking
• Tuition Remission Program
• Healthcare (medical, dental)
• Agency subsidized gym membership (on-site in Lawrence)
• License Renewal Paid by agency for RN's and Social Workers
• 20 Vacation Days, 12 Sick Days, and 12 Paid Holidays
• 403b Retirement Plan with agency match
• Mileage reimbursement
• Employee Assistance Program
• Commitment to promoting within
• Competitive salaries
• Social Work Licensing Program
• Flexible schedule and hybrid work opportunities
• Employee Referral Bonuses

Position Responsibility: The HCBS Hospital Liaison will be based in the hospital and will function as an integrated member of the hospital case management team to leverage collective expertise and skill to best support the discharge planning process. The liaison will also support patients in connecting to Home and Community Based services and manage complex service and support needs.
Essential Functions

• Other duties as indicated and assigned.
• Utilize the discharge planning tools currently used by the hospital
• Access Bamboo Health to facilitate communication regarding care transitions within the acute care setting and transitions to the community setting.
• Assess the patient's functional, health, and income status to determine eligibility and appropriateness for community long term care services or programs utilizing a standardized assessment tool.
• Identify and coordinate the resources necessary for a safe discharge to the community.
• Work as a team to cover essential functions of the HCBS Liaisons.
• Attend Care Management team meetings, daily huddles, interdisciplinary rounds, care conferences and other relevant meetings.
• Identify any existing barriers to discharge and document in the EMR.
• Support the hospital's efforts in connecting individuals to Home and Community Based programs and services that support a discharge to the community.
• Attend and participate in supervision, team, Home Care, and agency staff meetings as scheduled.
• Complete and maintain up-to-date documentation, including case files and statistical records as required by the agency.
• Outreach to and connect with assigned patients once the patient is discharged home.
• Participate in in-service training, educational offerings, and workshops to maintain professional expertise and develop additional skills.
• Review "red flags" and when to contact PCP.
• Leverage access to the hospital EMR, Epic, to facilitate real time communication with the members of the hospital care team.
• Review previously identified barriers to a successful transition and address those if indicated.
• Collaborate with hospital staff, physicians, HCBS partner providers, ASAPs, VNAs, Home Care Agencies to plan the necessary services for discharge.
• Maintain compliance with all mandated regulations of AgeSpan and the state and federal agencies contracted with.
• Comply with confidentiality and security requirements, including HIPPA Privacy and Security and attend any Mandatory trainings required by the hospital.
• Report to the care team any identified issues preventing the patient from remaining in the community.
• Review medications (both prescription and over the counter) and ensure patient has been able to obtain medications.
• Set up schedule to follow-up to include in-person, telephonic and telehealth contacts.
• Complete a patient-oriented needs assessment to identify issues or problems that inhibit secure independent living at home to enable patients to remain in the community.
• Outreach to and connect with assigned admitted patients and their families.
• Arrange a face-to-face visit once the patient is home to assess the home environment and social supports.
• Review the discharge plan and ensure all pieces are in place and the needs of the patient have not changed and are currently being met.
• Assist with scheduling follow up medical appointment(s) and ensure transportation or hands on assistance is available if needed.
• Initiate the ASAP enrollment if eligible, assessment and service authorization for patients newly referred to ASAP Home Care programs.
• Address any issues reported to the PCP in collaboration with the medical team and community supports.
• Comply with all hospital policies and procedures and adhere to all hospital protocols while on site at the hospital.
• Conduct trainings for hospital staff about HCBS alternatives to institutional care as indicated.
• Accept assignments from the hospital case management manager or designee

Qualifications: BA/BS in social work, human services or related field required; case management and experience with the older adult population preferred; Associates Degree with significant relevant work experience can be substituted for portion of degree. Reliable transportation and valid driver's license required as field work is an essential component of the position. Must be willing to obtain all immunizations as required by the hospital. Flexible work schedule offered.
Must be willing and able to complete community assessments on a regular basis and possess good written, verbal, interpersonal and computer skills, and the ability to work in an interdisciplinary team-based environment.
Hours per week : 37.5
AA/EOE
AgeSpan is strongly committed to fostering a professional environment that recognizes, respects, and encourages the unique contributions of a broad spectrum of qualified employees. It is important that our employees reflect the diverse communities we serve. We maintain a work atmosphere that allows people of varied backgrounds to grow professionally and contribute to our mission by promoting diversity, equity, inclusion, and work-life balance.
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