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.

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:
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.

• 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.

• Support for patient self-management by…