Care Coordinator, Social Worker

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Position Summary:

REACH, which stands for REadmission Advocates Collaborating in Healthcare, is an Orlando Health program that provides an extension of care management for patients after they are discharged from the hospital. REACH helps to connect a patient/family with community resources, referrals and other services that can help make managing healthcare easier and enhance quality of life. REACH services are available at all Orlando Health hospitals

Essential Functions:

• Takes the lead in ensuring the continuity and consistency of care, across the continuum (inpatient, emergency, and ambulatory care/ outpatient) to ensure integrated delivery across all settings to include the facilitation comprehensive discharge planning (in the hospital) and follow-up care (as an outpatient).
• Develops an effective working relationship with the Patient and Family Counselors/ Social Workers and the UR nurses to engage the patient/family to collaborate, advocate and problem solve, to support and enhance their functional ability, while ensuring an appropriate and timely discharge plan.
• Daily monitoring of progress towards discharge plans and/ or need to alter discharge plan due to change in patient condition / family needs with a priority placed on those patients at highest risk for complication/ admission/ readmission.
• Educates patients/ families with chronic illness about evidence-based standards of care to include self-management strategies.
• Identifies support needs for patients and their families, develops action plan(s), and provides creative guidance in initiating and overcoming any self-management strategies.
• Educates patients and families about the health care system and facilitates relationship building between the various settings.
• Contributes to problem solving within the team through communication, collaboration, data collection, obtaining consensus and evaluating outcomes of treatment options to include tracking patient progress towards care plan goals and revising the care plan as indicated.
• Refers patients to education regarding the healthcare delivery and reimbursement systems, prescription drug programs, health & wellness programs, community agencies, public and private organizations, housing options, and other services, as appropriate.
• Participates in clinical outcome measurement to include the identification of strategies that promote population health.
• Ensures patient safety in the performance of job functions to include the implementation of policies, procedures, and standards to support the assigned duties.
• Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state, and local standards.
• Maintains compliance with all Orlando Health policies and procedures.

• Master’s degree from an accredited school of Social Work, Mental Health, Psychology or Marriage and Family Therapy is required.

• None

Experience:

Two (2) years of direct clinical experience with an emphasis on the population to be served in the assigned area. Successful completion of master’s level internship within the population to be served may substitute the two (2) years of experience.