JOB DUTIES Serves as a member of a multidisciplinary team to assist in discharge planning needs identification and making referrals to community agencies. Provides leadership for other team members. Acts as liaison between professional staff, patients, their family, and outside agencies.
Effectively collaborates with all members of the health care team, including outside agencies, to develop and implement a multidisciplinary plan that delivers patient-centered care in a manner consistent with safe, efficient, and cost effective resource utilization. Screens and assesses patients to identify barriers or unmet needs as well as the need for ongoing service coordination. Prioritizes caseload based on acuity level and identified patient needs.
Formulates plan based on discharge planning assessment, diagnosis, age and outcome identification, taking physical, psychological, and emotional needs into consideration. Evaluates and modifies plan of care based on patient responses and attainment of expected outcomes. Evaluates comprehension of information presented in regards to discharge planning needs and provides additional education as needed.
Ensures timely documentation and communication of the next steps in the continuum of care to the patient, family, and agencies involved in care. Provide privacy for interviews/consultations for patients/families whenever possible, and is sensitive to surroundings when identifying and discussing additional support needed to foster self-management of medical needs and psychosocial stressors. Provides list of available agencies for referrals, as well as information on DNR and advanced directives when appropriate, and facilities discussion with patient/ family and community agency accepting referral as needed.
Is aware of psychosocial status and cognitive abilities of patient, and facilitates follow up with family members or next of kin as needed for discharge planning. Uses appropriate communication skills for specific ages, education, and cognitive level and is aware of psychosocial status and cognitive abilities of patient when facilitating discussions regarding discharge-planning needs. Is aware of child and elderly abuse issues and domestic violence, and makes the appropriate referrals.
Identifies potential safety hazards in the home environment and provides contact information for identified community resources in the discharge instructions that may assist in the elimination of such hazards. Performs other duties as assigned. MINIMUM EDUCATION, KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED Bachelor's in Social Work (BSW) or associated field, Masters (MSW) preferred.
A minimum of two (2) years’ experience in implementing social services and/or clinical medical case management in acute care, with extended care or rehabilitation experience preferred. Skills necessary to effectively communicate with various members of the health care team, other health care facilities, community health related organizations, various external parties and regulatory agencies. Education Associates (required) Experience A minimum of two (2) years’ experience in implementing social services and/or clinical medical case management in acute care for discharge planning purposes, with extended care or rehabilitation experience preferred.
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