Job Description
In support of patient progression practice, create optimal outcomes for the patient and the family by managing complex psychosocial and economic barriers to patient progression. Through advanced practice skills mobilizes resources to reduce risk to the patient and families secondary to social determinant based needs and challenges. Provides patient support with cultural humility to ensure that interventions by the care team are rendered respectfully to diverse populations. Identifies patient and/or families requiring coordination of continuing care or community support members of the care team. Reviews medical records, attends rounds, and responds to patient's needs. Applies knowledge based on professional experience. Understands and adheres to the practice standards consistent with patient progression and its contribution to the strategic plan. Works collaboratively with the RN Case Manager and the treatment team members to develop and coordinate a safe, timely and appropriate discharge plan across the care continuum, addressing psychosocial barriers, with multiple resource dependent level of care options that comply with regulations and laws regarding patient/family participation with planning and choice. Coordinates post-acute discharges for complex patients in collaboration with Care Management Discharge Manager. Identifies the need for and conducts in a timely fashion patient family meetings that result in decisions regarding advance directives, comfort measures, power of attorney, guardianship, conservatorship, and goals of care. Completes initial psychosocial screen of patients and families as indicated. Serves as the lead in addressing psychosocial needs of patients relating to social determinants of health, barriers to equal access to healthcare, and patient progression; this includes obtaining charity and financial resources, legal guardianship, adoptions, psychiatric referrals, and competency de