Conduct telephonic screenings and assessments, addressing clinical, behavioral, and socioeconomic needs of post-discharge patients.
Identify and proactively communicate with patients with particular risk factors and diagnoses to investigate for likelihood of readmission (assess condition status, monitor for clinical deterioration, assess level of self-care and support systems) and initiate post-hospital services as needed.
Serve as a liaison between the patient and the care team, and advocate on behalf of the patient/family/caregivers for access to services that support the patient’s preferences, quality of life, and safety and well-being.
Reassess and respond to changes in physical, behavioral, and psychosocial circumstances, as needed.
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