Location: West Orange, NJ view map
Work in collaboration with members of the rehabilitation care team to provide patient-centered support and resources to newly injured SCI (spinal cord injury) patients and their families. Serve as an advocate to identify and facilitate access to supportive educational and community resources, program enrollment, care coordination, system navigation, client advocacy, and other services, to enable them to achieve optimal levels of independence post-discharge. Collect data to support program evaluation; utilize evidence-based practices and a person-centered approach when selecting and administering assessments. Provide counseling to patients and family members with a concentration on adjustment to injury and psychosocial aspects associated with disability across the lifespan.
Responsibilities will include (but will not be limited to) the following:
- Assist newly injured SCI patients (and their families) when they are discharged from University Hospital (UH) to any inpatient rehabilitation setting, including the patient’s home.
- Meet with patients with SCI and their families shortly after admission.
- Support the communication/implementation of the discharge plan under the direction of the UH Trauma Care Team.
- Help identify educational and supportive resource needs (e.g., transportation, self-care resources) for navigating their transition.
- Work closely with individuals with SCI — and their families — throughout the inpatient phase at Kessler Institute Rehabilitation (KIR).
- Participate in trauma round discussions to promote greater visibility and increased contact with treating clinicians.
- During discharge planning, engage with patients and their families to help facilitate their transition home. Coordinate a “walk through” home visit to help prepare families to receive their newly injured family member.
- Participate in team meetings during inpatient rehabilitation at KIR to promote greater visibility and increased contact with treating clinicians and other members of the team.
- During and following the transition home, encourage and build confidence of newly injured SCI patients and their families by reinforcing skills learned in acute rehabilitation.
- On the day of discharge, provide support at patient’s home to ease logistical issues and provide a supportive environment.
- Aid in their transition and then ultimately back to the community to ensure they have access to ongoing SCI education and resources.
- Facilitate scheduling and coordinating first visit with KIR’s outpatient team.
- Continue to facilitate continuity of care by providing follow-up supportive and educational resources.
- Assist patients in building healthy coping mechanisms through the implementation of appropriate therapeutic strategies.
- Serve as the communication linkage between patient/family, healthcare providers, community organizations, and other related relationships. Consult with medical treatment teams and other community providers to communicate and obtain pertinent information related to patient goals, needs, and service coordination.
- Offer training and education that complements/augments hospital and community-based services.
- Teach self-advocacy skills and help patients access financial, legal, social, and caregiver support.
- Serve as an educational and supportive resource for all practice staff helping align patient post-discharge independence goals with treatment goals.
- Maintain supportive contact for up to 6 months after discharge, as newly injured patients and their families learn to implement new daily self-care and mobility routines.
- Graduate degree in nursing, social work, physical/occupational therapy, or similar field.
- Expertise in case management.
- Effective critical-thinking skills to plan and coordinate care.
- Experience with utilization review and discharge planning.
- Ability to write informative, concise, and timely reports, plans, and assessments.
In addition, the following qualification is preferred:
- At least five years of rehabilitation care experience in hospital, community health, or critical care.
Forward your résumé (MS Word or PDF), salary requirements, and cover letter to [email protected]. Please indicate the position(s) for which you are applying in the subject line.
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