Care Coordinator, Social Services - HealthCare Homeless - BH Point AMB

Summary

The Care Coordinator, Social Services, plays a vital role on an interdisciplinary healthcare team by providing and coordinating psychosocial care for patients and their families. This role involves conducting comprehensive assessments, facilitating appropriate interventions and service linkages, and identifying and addressing high-risk psychosocial factors that may impact a patient’s health and medical care. The Care Coordinator collaborates closely with healthcare professionals and community resources to support holistic, patient-centered care.

Location:

Broward Health Point – Shift: Shift 1 – FTE: 1.0

• Interview patients and families, identify and assess psycho‑social issues, and develop plans to meet their needs.
  • Conduct high‑risk screening interviews and continuously update assessments of referred patients within the required timeframe.
  • Assess and evaluate patients to identify psychosocial needs.
  • Conduct ongoing re‑assessments to identify changes in clinical or social needs that would impact the care of discharge plan.
  • Demonstrate evidence of engaging and maintaining frequency of contact with clients as specified within identified protocols.
• Complete and submit departmental productivity reports, statistics, monitors/indicators, and correspondence per established guidelines and time frames.
• Counsel patients and families to reduce emotional, psychosocial, and financial stresses of illness and enhance social functioning.
  • Intervene by providing patients and families with support and resources.
  • Assist patients in understanding and accessing financial, medical, and community resources.
  • Provide counseling/crisis intervention to enhance social functioning and coping mechanisms.
  • Identify and maintain current information on community resources.
  • Establish relationships with community agencies and services.
  • Identify concerns or barriers and work toward resolution through timely follow‑up for all concerns and service provision.
• Coordinate medical information including adherence, risk reduction, and primary and secondary education.
• Implement services for patients according to assessment and reassessment following regulatory guidelines.
  • Develop care plans with patient/family/significant other, physician, and other interdisciplinary team members.
  • Acquire appropriate contact information.
  • Coordinate and assist in securing needed services, including transportation, medication access, and other community resources.
  • Promote cost‑effective health planning for patients and the organization.
  • Complete and document all activities, including home visits and face‑to‑face visits, within requisite time frames specified by policy.
• Compile, record, and maintain documentation for care coordination intervention, departmental statistics, and performance improvement monitors/indicators in a complete, organized, accurate, and timely manner in the electronic data system.
  • Documentation is completed in the electronic data system and is concurrent and timely.
  • Reflects assessment and ongoing reassessment of bio‑psychosocial needs, care plan, and updates with each review per required guidelines, referrals to physician, etc.
  • Completes social services documentation according to departmental policy, Federal and State regulations, and grant guidelines.
  • Maintains accurate and current information in family records, including assessments, services, progress notes, interventions, reassessments, and interdisciplinary rounds.
  • Documents patient referrals and other services on appropriate forms and charts in progress notes.
• Document, establish, and foster open verbal communication with interdisciplinary healthcare team, patient, family, significant others, and community to facilitate optimal patient care and outcomes.
• Work with internal and external resources to negotiate and resolve problems and conflicts within care plans to ensure continuity of care.
• Communicate with patient/family/significant others on an ongoing basis and serve as a patient advocate.
• Document case plans and interventions in accordance with department policies and procedures to meet regulatory standards.
• Participate in medical staffing as required and communicate critical…