Transitions of care from hospital to post-acute settings (including home) are high risk times for patients that often result in adverse events and readmissions. The Alameda Alliance for Health has launched a new multidisciplinary Transitions of Care team focused on providing support, care coordination, and coaching/education for patients at increased risk of readmission. The Transition of Care (TOC) Social Worker works under the direct supervision of the Manager, Transition of Care and is part of a team of TOC Nurses and TOC Pharmacists. The TOC team is responsible for coordinating the care transition and follow-up from the acute hospital to home or facility for the initial 30 days post hospital discharge. While the TOC Social Worker participates in all aspects of the transition of care process, the Social Worker’s fundamental role is to assess, educate, and link members to community and partner resources in order to empower the member to meet their health care needs and ensure coordination and continuity of care following discharge from the hospital.
EDUCATION OR TRAINING EQUIVALENT TO:
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):