Complex Care Team Social Worker
Current• Provide consultation to all inpatient service lines for complex patient discharges across Brigham Health system• Assess barriers related to patient discharges and operationalize tasks to resolve barriers. • Ensure timely implementation of the CCT patients plan of care, appropriate patient progression to discharge, helping to navigate any barriers to care.• Visit BWH and BWFH CCT patients and / or families to explain role, program, and ensure all elements critical to the plan and… Show more • Provide consultation to all inpatient service lines for complex patient discharges across Brigham Health system• Assess barriers related to patient discharges and operationalize tasks to resolve barriers. • Ensure timely implementation of the CCT patients plan of care, appropriate patient progression to discharge, helping to navigate any barriers to care.• Visit BWH and BWFH CCT patients and / or families to explain role, program, and ensure all elements critical to the plan and trajectory of care have been communicated, including the goal length of stay.• Participate in patient and family meetings to support the plan of care and discharge plan. • Communicate with internal interdisciplinary team members and external providers to alert providers and team about potential issues and solutions to barriers.• Document regularly in electronic medical record and routes messages to providers and clinicians as needed.• Submit EOHHS state escalation forms to facilitate collaboration with state ombudsperson.• Participate in bi-weekly meetings with state ombudsperson to collaborate and develop d/c plan for escalated patients• Networks and forms alliances with post-acute-care providers, discharge agencies, managed care networks and third-party payors.• Maintains excellent relationships with leaders of post-acute care organizations both within and external to Partners Healthcare; acts as a link between Brigham and Women’s Hospital and these organizations. • Track data across BWH and BWFH related to all cases involving outside counsel, including guardianship, conservatorship, HCP affirmation and guardianship authority expansion.• Analyze legal data and develop action plan to reduce delay days when seeking legal authorities.• Support Home Hospital escalations to assess and provide support around patients’ psychosocial stressors. Show less