Manager of Care Transitions

Date Posted: 
Tue, 12/26/2017
Barbara McInnis House
Job summary: 

We are seeking an individual with an interest in transitions of care to join our Medical Respite team at Boston Health Care for the Homeless Program. Medical Respite at BHCHP consists of two separate programs, each with a different model of care, that together encompass 124 beds for homeless men and women too sick for street or shelter. This position will work with both clinical and non-clinical staff to focus on developing safe discharge plans for patients admitted to one of these two programs. Specifics duties include but are not limited to:

Primary Duties and Responsibilities: 

1) Supervising the floor case management staff to coordinate safe discharges for patients admitted to Medical Respite including
a. Discharge from Barbara McInnis House to Stacy Kirkpatrick House
b. Discharge to skilled nursing facility (completes MDS forms if needed)
c. Discharge to SUD treatment
d. Discharge to rest home
e. Discharge to housing
f. Discharge to shelter/street
2) Works with Barbara McInnis House leadership to oversee length of stay for both medical respite programs and helps the BMH/SKH team problem-solve complex cases when appropriate.
3) Ensures that the post discharge clinical pathway is followed and completed for patients who come to McInnis House after inpatient hospital stays.
4) Provides oversight for patients involved with the Behavioral Health Community Partner (BHCP) and Social Determinants of Health (HUB) programs who are admitted to BMH or SKH.
5) Responsible for ensuring that prompt communication occurs between inpatient and outpatient care teams for patients admitted to BMH.
6) Ensures completion of the appropriate care transitions metrics (medication reconciliation, post discharge follow up) when appropriate
7) Completes a post discharge phone call with patients within 72 hours of leaving BMH. Documents the result of this call in the clinical chart and communicates any issues to primary care team.
8) Tracks and reviews specific metrics related to care transitions at BMH.
9) Documents in the medical record as appropriate
10) Other duties as to be determined

Supervision Responsibilities: Provides direct supervision to case managers at BMH.
Secondary Duties: Provides support to teams around discharge planning and processes.

Qualifications and Requirements: 

Education and Experience:
• BA/BS required. RN with case management experience strongly preferred.
• 2 years of social service case management, home care or community health center experience in a supervisory capacity strongly preferred
• Excellent communication skills, oral and written
• Detail oriented with ability to multi-task
• Ability to work well with patients with complex medical problems
• Supervisory experience preferred
• Familiarity with local resources preferred
• Background in data analysis (Microsoft Access or Excel) preferred

How to Apply: 

Send your resume and cover letter to [email protected]. State "Manager of Care Transitions" in the subject line. Include your cover letter in the body of the email. Attach your resume in Word format, do not use file-sharing documents such as Google docs. If you are unable to email, please fax documents to (857) 654-1095 or mail them to BHCHP - HR, 780 Albany Street, Boston, MA 02118