Integration Specialist Transitions of Care

Sea Mar Community Health Centers, a Federally Qualified Health Center (FQHC) founded in 1978, is a community-based organization committed to providing quality, comprehensive health, human, housing, educational and cultural services to diverse communities, specializing in service to Latinos in Washington State. Sea Mar proudly serves all persons without regard to race, ethnicity, immigration status, gender, or sexual orientation, and regardless of ability to pay for services. Sea Mar's network of services includes more than 90 medical, dental, and behavioral health clinics and a wide variety of nutritional, social, and educational services. We are recruiting for the following position:

Sea Mar is a mandatory COVID-19 and flu vaccine organization

Position Summary

The Transitions of Care (TOC) Integration Specialist delivers specific time-limited services to identified patients designed to ensure health care continuity, avoid preventable negative outcomes among at-risk populations, and promote the safe and timely transfer of patients from one level of care to another. This position provides advocacy and education for the patient and/or their family or

caregiver during transitional periods between hospitals and/or other facilities and the patient’s home. The TOC Integration Specialist collaborates with hospital staff, discharge planners as well as care facilities to assist Sea Mar providers to resolve gaps in care, improve clinical outcomes related to the discharge plan, prevent all cause readmissions, and over utilization of hospital services.

The TOC Integration Specialist provides support with a focus on the following areas:

• Medication self-management: The TOC RN will act as a resource to the Integration Specialist as needed for medication reconciliation.

• Patient-centered record: Patient understands and uses a personal health record, MyChart, to facilitate communication and ensure continuity of care.

• Primary care and specialist follow up: Job Description

• Knowledge of Red Flags: Patient is knowledgeable about indicators that suggest their condition is worsening and how to respond.

The TOC Integration Specialist will have an understanding of patients with diverse medical, mental health, and social determinant of health challenges. Interventions with patients is time and scope limited, and TOC staff will not maintain an ongoing caseload. However, the TOC Integration Specialists are expected to complete outreach and transition of care activities for all patients identified who are willing to participate in the program. Active participation is encouraged related to community-wide efforts/coalitions to provide ever-improving comprehensive interdisciplinary care. This position is a unique, specialized position in the following ways:

• The TOC Integration Specialist will intensively case manage the patient for 30 days post discharge.

• The TOC Integration Specialist will be required to use a nationally standardized evidence based tool for documenting, tracking, care-planning, and quality metric reporting.

• The TOC Integration Specialist will be performing risk assessment for clients to identify level of need.

• The TOC Integration Specialist will be performing root cause analysis for all readmissions to personalize interventions and support.

• The TOC Integration Specialist will be responsible for monthly data gathering pertaining to appointment benchmarks, risk assessment stratification, readmissions, root cause analysis, barriers to care, and access to appointments. This data will be broken down by CMS identified diagnoses. Other metrics may be gathered related to clinical quality measures and measures identified by contracted entities such as Accountable Communities of Health and Medicaid/ Medicare organizations.

• The TOC Integration Specialist must maintain the standard knowledge base related to electronic health records, medication reconciliation and facility processes related to transitions of care. Additional skills include knowledge of CMS guidelines and standards for transitions of care, quality metric data gathering, and evidence-based practice standards for transitions of care including The Coleman Model.

Duties and Responsibilities

CORE RESPONSIBILITIES

• Support for patient self-management by enhancing health literacy, assessing baseline comprehension, values, and goals, and engaging family/caregivers to be active participants in the patient’s care. The TOC Integration Specialist will systematically provide education and supportive interventions to increase patient’s skills and confidence in managing their health problems, goal setting, and problem-solving.

• Advocate and negotiate to secure appropriate patient services. Support and empower patients to make informed decisions, and to navigate the healthcare system to access appropriate care. Build strong relationships with providers and discharge planners to maximize patient outcomes during periods of transition.

• Patient and family/caregiver education: Assess readiness to learn, learning styles, and use the teach-back method for care interventions. Use planned learning experiences to provide patients/families/caregivers opportunities to acquire the information and skills needed to make quality health decisions.

• Cross-setting communication and collaboration between primary care and

specialty/acute/rehabilitation care. Use of effective communication skills to gain and transmit information, encourage team participation, leverage electronic medical record tools, and design/implement processes to provide timely and successful patient transitions of care.

• Coaching and counseling of patients and family/caregivers regarding community resources, how to be prepared for “Ask Me Three”, and how to recognize red flags for complications.

• Use of the case management process to develop care plans, provide medication reconciliation with the assistance of the TOC RNs, and use evidence-based practice for interventions.

• Use of population health management tools to track and monitor select population characteristics and provide evidence-based practice interventions for select health populations. The TOC Integration Specialist will implement and evaluate interventions in the context of the health status, culture, and health needs of the populations of which the patient is a member.

• Use of teamwork and interdisciplinary collaboration, open communication, and shared decision making with stakeholders.

• Patient-centered care planning to include motivational interviewing and other techniques to elicit patient’s health care goals and priorities, individualizing care plan to transcend barriers and enhance patient outcomes.

Productivity Standards

• Conducts outreach to all patients appropriate for Transitions of Care Services within two business days post discharge from hospital. Ideally, connect with the patient and discharge planner/relevant hospital team in-person in the hospital prior to discharge. Conducts most future contacts over the phone, except where we might visit the patient at home, meet them in the office, or attend PCP appointments with them.

• Complete one discharge call to the patient within 48 business hours (or 2 attempts).

• Completes at least three attempts to contact all patients appropriate for Transitions of Care Services within eight business days post discharge from hospital. Contact includes speaking to a patient, their responsible party (family or caregiver), hospital, or other party (as agreed to by the patient). Provides at least one weekly contact / contact attempt with each patient for the 3 weeks following (30 days).

• Successful contacts include patient contacts, family/caregiver contacts, patient’s Sea Mar care team, and hospital contacts. A successful contact means that the TOC Integration Specialist has spoken directly to a contact and has communicated information regarding the patient. Collateral contacts throughout/as needed with o