Redington Fairview General Hospital Skowhegan, ME, USA
Primary responsibilities include working closely with interdisciplinary team to determine patients’ needs and coordinate care needed after discharge from hospital. Meet with patients and families to determine level of assistance that can be provided at home after discharge and make referrals to home health, skilled nursing facilities, assisted living, long-term care or hospice facilities. Connects patients with community resources to assist patient at home. Plan and attend family meetings with patient and medical/therapy team. Maintains and fosters relationships with resource partners, DHHS, regulators, and community leaders. Eliminates barriers to the patient’s good health and social concerns to decrease re-admissions.
Status : Full time