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Hospital to Home Liaison
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- Project Summary: The Hospital to Home Project is a new initiative in partnership with Emerson Hospital.
- The purpose of the project is to provide effective service coordination and successful transitions from hospital to home with the aim to reduce the rate of 90-day hospital readmissions, divert emergency room admissions, assess and address social care needs.
- Position Summary: Based mainly at Emerson Hospital and reporting to Minuteman Senior Service’s (MSS) Assistant Director, the Hospital to Home Liaison (HHL) works hand in hand with hospital staff at the inpatient level and Emergency Department (ED) to leverage collective expertise and skills to enable effective care coordination and successful care transitions to the home.
- S/he/they will expedite access to home and community-based care services for Emerson Hospital patients through Minuteman Senior Services or other local Aging Service Access Providers (depending on the patient’s community of residence).
- RESPONSIBILITIES include: Visit patients across settings (including in their home) to review community options and support the plan of care and family caregivers and provide information back to the hospital, physician practice, skilled nursing facilities (SNF)/Rehab and home health agencies (HHA) about the patient’s home environment and social supports.
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