Home Health Social Work Liaison

Detailed Overview

• Performs client assessments and acts as a liaison between the acute care facility and community care service to facilitate discharge planning from the acute care facility to the appropriate service in the community;
• assesses the client's care needs by completing various assessments and arranging for single or multi-service referrals to appropriate community services such as Home Health, Home Support, Residential and / or other related community services;
• collaborates with other community service providers to provide advice to the client, families and other health care professionals on the client's various discharge options;

manages short term Home Support hours for clients waiting to be discharged and / or referred to a community service. Responsibilities Arranges client referrals from staff within an assigned acute care facility that requires community care services upon discharge or a change in level of service.

Interviews and screens the client by gathering information from various sources and utilizes various client assessment tools to determine appropriate client care plan;

reviews client care plan to determine appropriate service upon discharge such as home support, nursing care and / or residential care.

Initiates and facilitates the development of a client care plan with other members of the interdisciplinary team; reviews hospital admissions / discharges to maintain awareness of client movement between the acute care facility and community services.

• Participates in discharge planning rounds in the acute care facility and facilitates timely discharge of patients ensuring appropriate resources are in place;
• assesses the client's eligibility for appropriate community services and / or placements. Liaises with the client, family, physician and other health care professionals to arrange for community services such as long term care, nursing care, home support and / or other community health services required for the client;
• ensures client receives access to appropriate information of available and eligible services. Facilitates timely exchange and provision of information regarding client care between the acute care facility and the community service to allow for individualized discharge planning;
• works with community service providers to ensure client care needs are met. Determines if client is capable of making decisions around client care plans, in collaboration with the interdisciplinary team;

refers client to appropriate health care professional for assistance and follows procedures around patient incapacity, respecting the client's right to privacy and confidentiality.

Completes and maintain complete documentation of client information such as forms, charts, records, statistical information and other related information, as required.

• Participates in quality improvement activities of the program by providing input into the development of indicators, standards, practices and procedures;
• provides recommendations to the Manager. Participates and assists in the orientation of new staff by developing and providing relevant information and materials;

acts as a preceptor as appropriate; identifies self-learning needs and attends relevant educational programs, as needed.

Advises acute care staff on whether clients are receiving community care services including the tracking of the number of hours of services provided to the patient awaiting placement and discharge.

Performs other related duties as assigned. Qualifications Education and Experience Bachelor's degree in Social work from an approved school of Social Work.

Two years' recent related clinical experience working with complex geriatric patients and adults with chronic or acute illnesses enabling care coordination and service planning across community and / or residential based health care systems, or an equivalent combination of social work education, training and experience.

Current full registration with the BC College of Social Workers. Skills and Abilities Knowledge of the broad health system, community resources and volunteer agencies, and their roles and responsibilities in providing a continuum of care Demonstrated ability to deal with others effectively Knowledge of gerontology, geriatrics and the needs of adults living with chronic illness Demonstrated ability to apply knowledge of theory and practice to the case management process Knowledge of relevant legislation, standards and policies Demonstrated ability to independently manage and prioritize caseload / workload and make decisions regarding interventions and access to subsidized resources Ability to communicate effectively both verbally and in writing Ability to operate related equipment including related computer software Physical ability to perform the duties of the position