Home Care Specialist

• Coordinates services within the clients home, community, delivery and pick up of medical equipment and supplies as needed based on program-specific workflows • Conduct occasional hospital visits to support hospital discharge planning or participate in case conferences for complex cases • Conducts home visits with the client following program-specific timelines to complete comprehensive assessments in partnership with the program funder, client and family to inform the development client goals within the program and an individualized client care plan • Arranges and adjusts home care services according to the care plan and in alignment with services contained within the program bundle • Monitors appropriate service allocation and bundle management • Attends program huddles with internal teams, hospital partners and/or program funders • Arranges appointments and liaise with the client’s primary care provider within set program specific timelines, supports the client to connect with primary care when required • Completes documentation after encounters with clients and their care team and communicates any risk-related events to the VHA team in a timely manner • Completes referrals to appropriate community services when needed and facilitates a seamless and supporting transition to these services • Provides direct care to the client and trains staff on delegated acts as required • Monitors program metrics and participates in program evaluation and process improvement