The Mobile Transitions of Care (TOC) Care Manager provides care management on behalf of the ACO’s medical homes. Mobile TOC Care Managers visit patients at acute and specialty care hospitals to ensure safe transitions of care inpatient to ongoing care in the medical home setting. The Care Manager will work collaboratively with the staff at hospital sites and at medical homes to facilitate better health outcomes and reduce readmission for patients.
Will follow role assignments that are in alignment with the Patient Centered Medical Home Standards, and participate in all Patient Centered Medical Home efforts
Engage with patients during hospitalization focusing on: reasons for hospitalization, reinforcing care management plan of care, updating information for the Medical Home Care Management team, plan of care post-discharge, and goal setting.
Complete assessments as appropriate, such as the Health Risk Assessments, initiate Care Plan, TOC Bundle, and others as needed.
Educate and support patients in health literacy, medication management, plan for follow-up and ongoing care, signs and symptoms of worsening conditions, functional or social needs, home and community-based services, advance directives, and other issues as identified.
Interface with hospital care team including nurses, social workers, case managers, hospitalists, and other staff responsible for utilization management and discharge planning. Engage with other stakeholders such as the patients’ family support network and external organizations the patient accesses for collaboration on patient success post-discharge.
Assess patient readiness for change and work with care team to ensure patients discharges to proper services, specifically for mental health and substance use treatment. Identify and address barriers to assure an efficient and complete transitions of care.
Participate in care team meetings and Integrated Care Team collaboration as necessary.
Develop relationships with staff in inpatient hospitals (general acute and behavioral health) and Medical Home Care Management staff. Gather and share patients medical home information with the hospital care team; Gather and share information about the hospital stay to the medical home, including discharge planning documents.
Work with the patient and medical home to secure timely follow-up appointments.
Communicate and document activities and outcomes to the patient’s medical home care manager regularly.
Assist in leading transitions of care training's for care management staff, focusing on patients hospitalized for behavioral health.
Participate in quality improvement initiative as identified.
Other duties as assigned.
Minimum of 3-5 years of recent work in care management, safety net/public health hospitals, FQHCs, academic medical centers, ambulatory care, physicians’ group, professional practice, and/or experience working in Community Mental Health Centers, Substance Use Treatment settings, outpatient mental health services; or combination thereof.
Excellent oral, written, and interpersonal communication skills.
Ability to work independently and as part of a team with a wide range of individuals from a variety of care delivery sites and community agencies.
Knowledge of and experience with systems used to improve population health and management of disease states such as diabetes, heart failure, COPD/asthma, mental health, and substance use.
Excellent organizational skills and ability to be self-driven
Knowledge and experience with electronic information systems.
Experience in program development and training/education.
Proficient computer skills
About Near North Health Service Corporation
Near North Health Service Corporation is an Equal Opportunity Employer. The Mission of Near North Health Service Corporation (NNHSC) is to provide access to high quality health care and to improve the health and well-being of the diverse populations and communities we serve. We are a culturally sensitive, patient centered community health center that empowers individuals through education and health prevention, regardless of one’s ability to pay.