Patients transitioning out of the acute inpatient care setting—including those discharged to home, shelter, or skilled nursing settings, among others—remain among the most vulnerable to experiencing fragmentation and gaps in care, increasing risk for preventable adverse outcomes and downstream costs of care. Safety net hospitals and health systems face unique challenges in delivering effective transitional care in the post-inpatient period, serving a patient population with an overall higher risk of readmission and greater unmet behavioral health, economic, housing and social needs. Meeting these needs requires strong collaboration, coordination, integration, and management of care planning and delivery across disciplines within and beyond the hospital inpatient setting and outside the health care sector.

Across NYC Health + Hospitals, the Transitional Care Management (TCM) program is a standardized and systemwide program that aims to support successful transitions for high-risk patients from hospital inpatient to community settings. Within the program, Transitional Care Coordinators (TCCs) and Transitional Care Managers work collaboratively alongside interdisciplinary teams to perform transitional care activities, including in both discharge planning and post-discharge monitoring phases. During the inpatient admission, the patient is screened for root causes of admission, unmet medical or social needs, and other re-admission risks. Staff then work with patients, outpatient caregivers and providers, and the inpatient interdisciplinary team to develop and implement a care plan customized to the patient’s needs. Upon discharge, transitional care staff monitor the patient with regular callbacks for 30 days post-discharge. Though operationalized by staff embedded within care teams at each acute care hospital, the TCM program is a systemwide program leveraging standardized operational guidance, workforce training, program policies, and monitoring and evaluation tools.

The Social Work System Lead (TCM) for will serve as the primary lead for social work aspects of transitional care, playing a critical role in enhancing the effectiveness and coordination of social work interventions for patients receiving TCM services. The Social Work Lead will be a key part of the TCM System Implementation Team, collaborating with hospital-based transitional care social work leads, TCM program directors, and facility leadership, to support implementation of the TCM program, including through the development policies, workflows, operational guidance, tools and training. Working closely with both internal and external partners, including city agencies, community-based organizations and social service providers, the Social Work Lead will develop the strategy and partnerships needed for frontline teams to deliver consistent and effective whole- person transitional care, focusing on the systemwide infrastructure and support to address complex transitional social work need

The responsibilities of the SW Lead will include but are not limited to: • Develop and implement standardized enterprise- wise policies, workflows, operational guidance, and standards for social work and behavioral health interventions within the TCM program, ensuring alignment with organizational goals, best practices and regulatory requirements. • Collaborate with the Training Director to design and deliver comprehensive training programs for TCM staff and interdisciplinary teams, focusing on assessing and addressing complex social determinants of health, enhancing patient engagement, and supporting effective care transitions • Work collaboratively with other Central Office stakeholders (e.g. Office of Population Health, Ambulatory Care, Office of Behavioral Health) to align with other care management programs and social work interventions, developing linkages between programs, and shared training and workflows where appropriate • Foster strong collaboration and integration among different disciplines across the system, including Transitional Care Coordinators, Accountable Care Managers, Social Workers and medical providers • Collaborate with the Epic team to optimize the Compass Rose TCM build to better address social needs, identifying opportunities and tools to improve workflows, documentation and performance management. • Co-lead regular office hours for frontline staff to participate, provide feedback and be able to address social work-related barriers to effective transitional care • Collaborate with the Program Director to hold quarterly meetings with each site leadership to assess gaps in training program, assess fidelity to the TCM, gain feedback, and summarize data on program implementation and impact • Regularly visit with all system acute care hospitals to identify and support the needs of facility, TCM leadership and their staff. • Utilize data analytics to monitor key performance indicators to assess the impact of social work interventions on patient outcomes and resource utilization, providing regular reports and recommendations for leadership to demonstrate program impact and identify areas for enhancement. • Lead quality improvement initiatives to monitor and evaluate the effectiveness of social work interventions within TCM, utilizing data-driven insights to continuously improve patient outcomes and program efficiency • Participating in ongoing education, specialized training and research to learn and maintain skills needed for transitional care management. • Perform other duties as assigned.

2. Six (6) years of experience in Clinical Social Work, of which three (3) years are in a health care or medical care setting including psychiatric and medical social work, and three (3) years in a supervisory, consultative and administrative capacity in a organization adhering to acceptable standards with knowledge of administration, with administrative and managerial skills and abilities; or,

3. A satisfactory completion of training and experience. However, all applicants/incumbents must possess licensure as described in (1) above at the time of appointment; and,

4.Demonstrated ability to function productively and cooperatively with Director of Social Work, Medical Staff, and Administrative Staff and to supervise effectively.

Department Preferences • At least 5 years of full-time clinical, operational, or administrative experience in hospital social work, preferably in a leadership role • At least 2 years’ experience in care management programming. • Special Equipment/Machines Operated: Microsoft Office (word, excel, powerpoint), Process mapping software (acrobat, MS Visio, LucidChart), Epic (Electronic Medical Record), Cisco WebEx, PDF software (Acrobat, Preview) • Social needs: Demonstrates strong understanding of social determinants of health, their impact on patient outcomes, and how interventions to address social determinants can be integrated into healthcare delivery • Behavioral Health: Demonstrates knowledge of behavioral health needs, interventions, and post-discharge services and their integration into care plans for patients admitted to Med/Surg service. • Health equity: Able to use knowledge of health disparities and culturally competent and trauma-informed care delivery, and integrate into systemwide programming. • Training: Proficient in design and delivery of comprehensive training programs for diverse stakeholder groups • Project Management: Independently develops and/or uses an organized approach to managing multiple deadlines in parallel across different initiatives and teams. • Workflow Operations: Analyzes and breaks down complex operations into discrete process steps and branches. • Quality Improvement: Uses core quality improvement tools to guide process improvement, including outcome, process, and balancing measures; driver diagrams; and run charts. • Interpersonal teams: Works well with individuals of different personality types, work styles, and backgrounds. Comfortable leading groups or teams, including with more senior employees. • Strong written and verbal communication skills and comfort managing complex teams • Experience in developing and implementing standardized policies and workflows across a healthcare system. • High proficiency in managing in-person and virtual meetings, including goal-direction, attention to time management, and ability to encourage collective participation. • Ability to identify workflow challenges, independently explore and identify root causes, and work through steps in order to develop solutions. • High degree of organization and ability to manage multiple projects concurrently, including under tight timelines. • High proficiency in communicating workflows through visual flow diagrams and process mapping techniques. • Comfort and independence communicating across departments or disciplines, including in an instructional or training capacity. Uses an empathic and non-punitive approach, eliciting new information and challenges. • Strong proficiency in data analytics and interpretation. Able to manipulate and analyze large data sets, including for operational or financial planning purposes. Identifies data needs and modeling assumptions. Visualizes data in tables and charts for lay interpretability. • Independent problem-solving initiative and ability to work through obstacles to achieve desired outcomes. • Punctuality, organization, and ability to perform regular activities with minimal oversight.

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