Transitional Care Manager

Freedmen's Medicine, House Calls of DC is a home-based primary care practice focused on chronic disease management. The priority population that we serve is persons with 1+ chronic medical condition and a behavioral health diagnosis or SUD. As a home-based primary care practice, we provide clinical services in the area that the person calls their home. Currently, we have patients that reside in private homes, individual apartments, group homes, shared living arrangements, recovery housing, residential SUD treatment facilities, hotels/motels, permanent supportive housing, low-barrier shelters, cars, tents, and other places not meant for housing. The Freedmen's Medicine medical practice model is an integrated clinical practice that provides the full scope of medical management with behavioral health case management, psychiatric services, and psychotherapy/counseling. Freedmen's Medicine deploys an evidence-based hospital/skilled nursing facility transitions of care model. The intervention is based on the Naylor transitions model. The HCDC Transitions in Care Manager plays a pivotal role in ensuring safe, effective, and person-centered transitions across care settings. The Manager is responsible for supervising transitional care specialists who identify and enroll patients in the program, collaborating with health care staff to plan an accelerated and safe transition, coordinating health care, educating patients and caregivers, and enrolling patients in additional care team programs that may benefit the patient. The ultimate goal of House Calls of DC's care transitions program is to accelerate well-coordinated transitions to maintain in the community while working towards with optimal health, safety, and independence and prolonged stay in the community. Transitional Care Management (Mary Naylor TCM Framework) Identify patients that could benefit from the care transition support through our TCM program and enroll them in the program (document consent) Serve as the single point of contact for patients and facility social workers/discharge workers during transitions. Conduct comprehensive assessments pre-discharge to identify medical, psychosocial, and functional needs. Complete a screen of social needs and medical needs post-discharge and identify ways /HCDC programs to address social needs impacting the patient's health or ability to stay in the community Develop and implement individualized care transition plans in collaboration with the patient, family, and facility interdisciplinary team that supports the patient's health and social needs to enable a prolonged stay in the community (to reduce avoidable readmissions) For patients transitioning to a nursing home or assisted living facility: Evaluate readiness for transition based on clinical stability, functional status, and support systems. Educate patients and families on differences in care levels and expectations. Proactively arrange home health services, durable medical equipment, and transportation as needed. Ensure continuity of care by coordinating with primary care providers, specialists, and community resources and services regularly. Monitor patient progress and adjust care plans as needed during the 30-day post-discharge period. Conduct home visits or telehealth check-ins within 48 hours of discharge to assess safety and adherence to care plans and ensure the patient has all they need to remain safe in the first week post-discharge (e.g., medications, aides, DME, etc.) Continue to address barriers to recovery such as medication access, nutrition, and social support through coordination with other HCDC care programs, as appropriate. Educate patients and caregivers on medications, self-care strategies, warning signs, and follow-up needs. Develop a post-discharge plan (90 days), in partnership with the patient to be supported by the HCDC Care Manager Provide intensive follow-up for 90 days post discharge Coordination & Communication Work closely with discharge planners, social workers, and case managers to streamline transitions. Own the transition process from discharge through the 30-day post-discharge period. Engage with patient no less than weekly post-discharge for the first 30-days to address any additional clinical, social, or other needs that arise. Maintain detailed documentation of interventions, patient status, and outcomes in the

HCDC EMR

(Athena) Communicate regularly with patients, families, and providers to ensure alignment and satisfaction. Additional Responsibilities Participate in quality improvement initiatives related to transitional care. Track and report metrics such as readmission rates, patient engagement, and care plan adherence to the Executive Leadership team regularly. Stay current on best practices, regulatory requirements, and community resources. Coordinate agenda preparation and team availability /preparedness for meetings with hospitals, nursing facilities, assisted living facilities, and DC government and others, as appropriate. Provide mentorship or training to new care transition staff as needed. Support patients with advance care planning and goals-of-care discussions. Other duties, as requested. Qualifications RN, LCSW, or other clinical license preferred but not required. Minimum 2 years of experience in case management, discharge planning, or transitional care preferred, but not required. Familiarity with the Mary Naylor TCM model or similar evidence-based frameworks. Strong communication, organizational, and problem-solving skills. Ability to work independently and collaboratively across care settings.

Job Type:

Full-time Pay:

$28.00 - $32.00 per hour

Benefits:

401(k) 401(k) matching Dental insurance Health insurance Paid time off Vision insurance

Work Location:

In person