- UnityPoint Health (Des Moines, IA)
- …+ Tighter integration with ambulatory care management team, especially with high risk , chronically ill patients. + Standardize alert to cross continuum ... testing, Outpatient Therapies (Pulmonary Rehab, Cardiac Rehab, Physical and/or Occupational Therapy), Palliative Care or Hospice. + Ensure that the patient's… more
- Texas Health Resources (Plano, TX)
- …for all assigned patients and collaborates with the interdisciplinary team to identify high risk patients whose THRIL score may not have indicated appropriately. ... care conferences for complex transitions, placement, and palliative care needs. . Reviews the Texas...(THRIL) scores daily for all assigned patients . Identify high risk patients whose THRIL score .… more
- WMCHealth (West Nyack, NY)
- … care management focused on evaluating and coordinating post-hospitalization needs of patients at risk for rehospitalization, and high risk , high cost ... of living wills and advance care planning, and, when appropriate, begins palliative care consultations. . Develops and collects data; analyzes utilization of… more
- Virginia Mason Franciscan Health (Lakewood, WA)
- …resources; mental health service and support coordination; grave disability, palliative care /end-of-life, and hospice patient/family support, referrals, and ... of the Masters Social Worker include: crisis intervention, patient/family intervention, high - risk screening, brief counseling, referrals for financial or other… more
- Cleveland Clinic (Cleveland, OH)
- Works collaboratively with multidisciplinary care team staff across the continuum of care for high risk patients. Provides coordination of care and ... + Conducts targeted outreach to a defined panel of high risk patients (chronic illness, lack of...and transitional care social work, rehabilitation, pharmacy, palliative care and others. + Defines and… more
- Virginia Mason Franciscan Health (Silverdale, WA)
- …the Licensed Clinical Social Worker includes crisis intervention, patient/family intervention, high risk screening, brief counseling, referring for financial or ... resources; mental health service and support coordination; grave disability, palliative care /end-of-life, and hospice patient/family support, referrals, and… more
- AdventHealth (Apopka, FL)
- …psychosocial needs and coordinates and facilitates the development of a discharge plan of care for high - risk patient populations. This role will receive ... referrals for individuals from at- risk populations from interdisciplinary team...the following: Home Health, Infusion Services, Durable Medical Equipment, Palliative Care , Hospice, Outpatient Services, Transitions of… more
- St. Luke's University Health Network (Quakertown, PA)
- …discharge plan as additional information is acquired. + Proactively considers options such as palliative care , homecare and other services that work to keep the ... Medicare (IMM), Medicare Outpatient Observation Notice (MOON), Bundle Payment Care Initiative (BPCI) notification. + Monitors risk ...to hear as it relates to normal conversations and high and low frequencies and to touch as related… more
- St. Luke's University Health Network (Easton, PA)
- …as additional information is obtained or goals change. + Proactively considers options such as palliative care , home care and other services that work to ... care and a successful discharge plan. + Monitors risk assessment using available tools and implements discharge interventions...to hear as it relates to normal conversations and high and low frequencies and to touch as related… more
- St. Luke's University Health Network (Bethlehem, PA)
- …as additional information is obtained or goals change. + Proactively considers options such as palliative care , home care and other services that work to ... care and a successful discharge plan. + Monitors risk assessment using available tools and implements discharge interventions...to hear as it relates to normal conversations and high and low frequencies and to touch as related… more