DSCC Hospital Liaison (5010 BUS/ADMINV ASSOC 2)

Position Summary Under the supervision of the Assistant Director of Enrollment and Specialty Care, the DSCC hospital liaison is responsible for outreach activities regarding all 3 DSCC programs – Core, Connect Care, and Home Care – as well as conducting in-person hospital visits to DSCC participants. The hospital liaison coordinates and facilitates the timely discharge of Medically Fragile Technology Dependent (MFTD) children eligible for the Home Care Program from the inpatient hospital setting and assists in the facilitation of the care coordination plan with the child's physicians. The hospital liaison has a physical presence in the hospitals, allowing DSCC and hospital staff to work collaboratively. In conjunction with hospital staff, the hospital liaison identifies the need for home care or other DSCC services and works collectively with the hospital and the DSCC Care Coordination Team to ensure referrals for DSCC services have been made. Duties Responsibilities 1. Identifies the need for DSCC services (Home Care, Core, Connect Care) and works collaboratively with hospital staff and the DSCC Care Coordination Team to ensure those services are ready at the time of discharge from the inpatient hospital setting. Those services include but may not be limited to in-home nursing and medical equipment and supplies, and care coordination. 2. Attends hospital rounds, meet with case managers/providers/families; reviews medical documentation to determine eligibility for DSCC programs and services. 3. Explains programs, services, enrollment, and care coordination to eligible families. Obtains documentation and partners with the hospital case management team and Enrollment Team/Care Coordination Team to address identified needs (for example, home modifications, identification of PCP in the community, transportation for medical appointments, other specialized equipment, and supplies). 4. Assists and collaborates as necessary with Connect Care participants while hospitalized, collecting clinical and treatment information, obtaining current participant’s contact information for hard-to-reach members, or facilitating communication with the family, hospital team, and DSCC Transition of Care Coordinator. 5. Contributes as a subject matter expert on health education initiatives such as immunizations, weight management, the importance of physical activities, etc. 6. Offers clinical consultation when requested by care coordination team members. 7. Elicits health and medical histories; assesses the social history and family history of children requesting, or eligible for, DSCC services in the hospital inpatient setting or the office setting of large group practices caring for medically fragile/technology dependent children and/or children with special health care needs. 8. Contributes data documentation such as care coordination activities notes into the organization’s electronic records. 9. Participates as a team member for the Home Care Regional Office multi-disciplinary and enrollment teams. Participates in monthly multidisciplinary case reviews as able; discuss and problem-solve complex situations (including input from the hospital team) with Enrollment Team/Care Coordination Team and leadership as indicated. 10. Assists in the development of the care coordination plan with the child’s physician(s), hospitals, and DSCC Care Coordinators. Participates in multidisciplinary team rounds, family care conferences, and discharge meetings; reach out to providers and families to identify care coordination needs; partner with the Enrollment and Care Coordination Team to develop care coordination plan 11. Participates in outreach activities. Examples of outreach activities include preparing and delivering presentations to hospitals including social workers, case managers, and providers with the goal of explaining DSCC programs, services, and eligibility. Staffs booths at conferences.