<p>Discover. Achieve. Succeed. #BeHere</p> <p>Location: US:WI:MILWAUKEE at our FROEDTERT HOSPITAL facility.</p> <p>This job is ON - SITE.</p> <p>$5,000 sign on bonus!</p> <p>FTE: 1.000000</p> <p>Shift: 1</p> <p>Schedule: Monday-Friday working 0800-1630</p> <p>Job Summary:</p> <p>The ED Care Coordinator (EDCC) functions as an essential part of a multidisciplinary team that supports the overall mission and objectives of the ED Care Coordination Program within Froedtert Hospital. The EDCC is committed to enhancing the health outcomes of patients with complex biopsychosocial needs and seeks to ensure the effective coordination and provision of healthcare services in the hospital, ambulatory and community settings. Using a myriad of interventions and strategies, the EDCC also aims to decrease the unnecessary and inappropriate reliance on ED (emergency department) and hospital resources for primary care needs and specifically targets patients identified as "high utilizers." ED high utilization is defined as a frequency of 3 or more ED visits in 30 days, 6 or more ED visits in 90 days, or 7 or more visit in 12 months. The EDCC serves as a single point of contact linking social, community, and health service providers to any patient (regardless of medical home or medical homelessness) who encounter barriers to accessing needed resources.</p> <p>EDCC Objectives:</p> <ul> <li>Improve health outcomes and the quality of life of patients with complex health and/or psychosocial issues </li><li>Decrease medically unnecessary, inappropriate and preventable ED/inpatient admissions. </li><li>Decreasing ED and inpatient admissions and readmissions </li><li>Develop proactive and effective care plans for patients meeting established criteria </li><li>Assist "at-risk" patients by identifying gaps in care and connecting them with relevant resources </li><li>Develop trusting relationships with this population to aid in directing their care to the ambulatory setting for management. </li></ul> <p>EDCC Responsibilities:</p> <p>Reviews ED Care Plan referrals:</p> <ul> <li>Determine if patients meet program criteria. 6+ ED visits over 6 months, 12+ ED visits over 12 months, and/or present with acutely challenging behaviors that require intervention to maintain safety among patient(s) and staff. Only FMLH ED visits are considered when determining if a patient meets criteria </li><li>Collaborate with patient's community based teams to better understand their needs </li><li>Review drafted FMLH ED Care Plans with ED Psychiatry and/or ED Physician to receive appropriate recommendations o Develops individual care plans based on the patient's self-reported and perceived needs </li><li>Documents care plan in EMR </li><li>Review daily Charge Reports to identify patients who present with acute events that may benefit from a care plan </li></ul> <p>Maintains list of patients with active care plans:</p> <ul> <li>Reviews and updates patient care plans on a quarterly basis </li><li>Meets with patients during all ED visits. Follows patient during inpatient admission if reason for admission is not a medical issue (ie. Social admits) </li><li>Completes post-discharge follow-up calls to remind patients of their upcoming appointments and assist with accessing needed supportive services in the community. </li><li>Collects relevant data about the frequency, types, and etiology of ED/inpatient encounters and provides targeted interventions that aim to decrease inappropriate utilization </li></ul> <p>Serves as patient's advocate:</p> <ul> <li>Complete appropriate assessments and/or screens when meeting with patients in the ED or inpatient </li><li>Offers crisis intervention counseling for patients and their loved ones as needed </li><li>Provides patient education on available community resources, transportation options and housing. </li><li>Maintains appropriate contact with providers and managed care organizations who support patients in the community </li><li>Connects patients with the federally qualified health centers (FQHCs) in their community if applicable </li><li>Provide patient with education on My Chart, MTM, and other patient self-serve services available </li></ul> <p>Collaborates with internal and external disciplines to best meet patient's needs:</p> <ul> <li>Ensure identified patient's community supports and providers are accurately identified </li><li>Maintains appropriate contact with patient's community supports and providers </li><li>Participates in the Emergency Department Care Coordination (EDCC) Care Manager's workgroup through the Milwaukee Health Care Partnership </li><li>Engage in quarterly meetings with United Health Care Community Plan team and Froedtert Sickle Cell Frequent Utilizer team </li></ul> <p>Collaborates with Inpatient Care Management team on shared patients:</p> <ul> <li>Attend weekly Outlier Meetings with the goal to be aware of any complex discharges that have potential to quickly return to ED </li><li>Notified by inpatient staff of patients who may leave AMA, but have high chance to return; or patients who are not complying with discharge plan and are believed to return to the ED. Become proactively involved by either reviewing patient with inpatient staff, meeting with patient, and/or notifying appropriate staff within the ED. </li></ul> <p>Completes ED social work referrals as able/appropriate:</p> <ul> <li>Provides targeted interventions that support patients and loved ones during crises </li><li>Assist patients in problem solving and decision making </li><li>Completes biopsychosocial patient assessments to determine needs </li><li>Directs patients to appropriate community resources </li><li>Collaborates with multidisciplinary team to support safe and effective discharge from hospital </li><li>Provides education and assistance completing a Health Care Power of Attorney </li><li>Follow up on 2nd/3rd shift community outreach requests </li><li>Supports patients by helping to navigate complex medical, psychosocial, and behavioral health issues </li><li>Possesses knowledge and is able to effectively support patients diagnosed with behavioral health/AODA disorders </li><li>Maintains knowledge of current community resources </li></ul> <p>EXPERIENCE DESCRIPTION:</p> <p>A minimum of two years experience in an acute care setting is preferred. Casework in medical social work is preferred.</p> <p>EDUCATION DESCRIPTION:</p> <p>Master's degree in Social Work is required.</p> <p>SPECIAL SKILLS DESCRIPTION:</p> <p>Interpersonal skills necessary to obtain information from patients, to provide counseling to patients/families, and interact effectively with patients and families. Analytical skills necessary to assess patients needs, develop associated discharge planning and develop solutions to problems concerning patients mental and physical well being.</p> <p>LICENSURE DESCRIPTION:</p> <p>Current State of Wisconsin license as a social worker is required.</p> <p>Perks & Benefits at Froedtert Health</p> <p>Froedtert Health Offers a variety of perks & benefits to staff, depending on your role you may be eligible for the following:</p> <ul> <li>Paid time off </li><li>Growth opportunity- Career Pathways & Career Tuition Assistance, CEU opportunities </li><li>Academic Partnership with the Medical College of Wisconsin </li><li>Referral bonuses </li><li>Retirement plan - 403b </li><li>Medical, Dental, Vision, Life Insurance, Short & Long Term Disability, Free Workplace Clinics </li><li>Employee Assistance Programs, Adoption Assistance, Healthy Contributions, Care@Work, Moving Assistance, Discounts on gym memberships, travel and other work life benefits available </li></ul> <p>The Froedtert & the Medical College of Wisconsin regional health network is a partnership between Froedtert Health and the Medical College of Wisconsin supporting a shared mission of patient care, innovation, medical research and education. Our health network operates eastern Wisconsin's only academic medical center and adult Level I Trauma center engaged in thousands of clinical trials and studies. The Froedtert & MCW health network, which includes ten hospitals, nearly 2,000 physicians and more than 45 health centers and clinics draw patients from throughout the Midwest and the nation.</p> <p>We are proud to be an Equal Opportunity Employer who values and maintains an environment that attracts, recruits, engages and retains a diverse workforce. We welcome protected veterans to share their priority consideration status with us at 262-439-1961. We maintain a drug-free workplace and perform pre-employment substance abuse testing. During your application and interview process, if you have a need that requires an accommodation, please contact us at 262-439-1961. We will attempt to fulfill all reasonable accommodation requests.</p>