The Home Care Liaison facilitates the transfer of patients from a hospital or skilled nursing facility to the care of the home health agency in compliance with applicable laws, regulations and Agency policies.
Carries out the agency’s mission, philosophy, goals and objectives within guidelines of Agency policy and position function.
Interprets and implements the Agency’s philosophy to staff and members of the community.
Works with the Hospital team (social worker, discharge planner, skilled nursing facility staff and or nurse) to assess patient’s home-care needs and establish a discharge plan.
Interviews patients and family to assess the patient’s understanding of illness and determine patient’s home environment and support system.
Evaluates patient’s level of comprehension if procedures and/or treatment need to be performed, e.g. insulin injections, dressings, ostomy care.
Discusses with medical staff, treatment in hospital, and the patient’s response to illness.
Explains home health agency services and policies to patient and family.
Assesses third-party coverage and determines if coverage is sufficient to cover the patient’s needs at home. Discusses with patient and family other community resources, where appropriate.
Makes referrals to other agencies if additional services are needed, such as meals from a nutrition center, volunteer services, etc.
Arranges for special medical supplies and/or equipment needed, in coordination with discharge planner or social worker.
Assures that the home health agency is ready to meet the patient’s needs at discharge by communicating the information to the home health agency regarding the patient and by arranging for the Agency’s staff to learn unfamiliar procedures related to the patient’s
Provides feedback to hospital health team and/or skilled nursing facility after the patient’s discharge.
Participates in orientation of Agency staff.
Participates in Agency committees as requested.
Participates in performance improvement activities and peer record reviews.
Participates in all office specific duties and responsibilities related to the position.
Participates in evaluating overall position performance, goal setting and achievement, and performance improvement plan.
Current New York State license as a Registered Professional Nurse/Licensed Social Worker
Bachelor of Science degree in Nursing from an approved school is preferred.
LMSW/LCSW in Social Work
One-two years of community health experience in a Certified Home Health Agency (CHHA) or Long Term Home Health Care Program (LTHHCP).