Under the supervision of the Bridge Care Coordinator Supervisor works within the Community Care Transitions Program approved by the Centers for Medicare and Medicaid, an intervention designed to reduce thirty day re-hospitalizations for at-risk older adults (65 and older). Bridge Care Coordinators will connect individuals with community resources and medical providers through a person centered process. Participants will be identified by hospital staff during the discharge process, meet before discharge with follow-up visits in the community setting for thirty days. Maintains communication with appropriate hospital and TCOA staff.
Essential Job Functions: (Reasonable accommodations will be provided, if necessary, for individuals with disabilities who can perform the essential job functions.)
Provide Bridge Model transitional care services to older adults and their caregivers.
Conduct comprehensive social work assessments before and after client discharges from the partner hospital(s).
Work directly with clients and caregivers to address unmet needs by connecting necessary care providers to each other or to the client/caregiver, exchanging health information in a timely manner and setting up necessary community services before and after discharge using a person-centered approach and care plan.
Develop and maintain partnerships with organizations involved in client care. Examples of organizations include, but are not limited to, hospitals, home health care providers, community physicians and clinics, volunteer organizations, faith-based organizations, and local businesses involved in care provision.
Document every transition in accordance with agency and program guidelines in the appropriate database.
Work with clients in multiple settings, including making home visits.
Work with a flexible time schedule.
Order and monitor services for client, post discharge.
Examples of job functions listed do not include all tasks which may be found in this position. Duties and responsibilities may be added, deleted or modified at any time.
Knowledge, Skills & Abilities:
Commitment to the organization’s missions and goals and to represent the Agency in a professional manner.
Computer skills sufficient to learn specific departmental software programs.
Ability to work independently or as part of a team and maintain confidential information regarding all aspects of client, volunteer, employee and agency information.
Ability to communicate effectively and establish good relationships with staff, clients, volunteers and vendors.
Cultural competency of the community served; bilingual/bicultural as appropriate to the community.
Familiarity with local resources
Person-centered, motivational, and empathetic interviewing skills.
Must be able to adjust priorities to meet deadlines in a timely manner.
Must have excellent verbal, writing, and comprehensive social work assessment skills.
Ability to make quick, sound and effective decisions.
Working knowledge of budgets, financial resources and accounting principles.
Ability to meet department standards with regard to job knowledge, client focus, initiative, productivity, communication, teamwork and attendance.Additional Requirements:
A Master’s degree in social work is required.
A current Michigan Social Work license in good standing is required.
A minimum of 2 years experience in healthcare, social services or a related field and clinical experience with older adults and caregivers is required.
Must possess a current Michigan Driver’s license in good standing (less than 4 points preferred)"
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