Social Worker

Responsibilities:

• Discharge Planning Competencies
• Interviews and collaborates with patient/family to assess aftercare options providing guidance information and support in decision making.
• Coordinates all aspects of the discharge process for patients with complex post-acute needs returning home.
• Develops alternative discharge plans and coordinates with Team Leader, peers, and Case Manager as needed to facilitate resolution of problem dispositions or difficult patients/families.
• Facilitates and monitors the discharge plans and arrangements for assigned patients going to boarding homes, assisted living homes, skilled care, long term care, hospice, or rehabilitation (physical, psychiatric, drug and/or alcohol).
• Refers to community services as needed, including (but not limited to): office of aging, CYS, CVIM, MH/IDD, crisis, domestic violence, dialysis services, VNA, etc.
• Works with patients and their families to help them understand the impact their illness may have on their lifestyle, family, relationships and home situation.
• Coordinates individual patient care conferences when deemed necessary, including appropriate inpatient and outpatient personnel/agencies.
• Develops a discharge plan in a timely manner to maintain lowest cost to the hospital, while ensuring a comprehensive quality plan.
• Procures signature on second Medicare Important Message (IMM) form for assigned patients as required by CMS 48 hours prior to discharge.
• Intervention Competencies
• Discusses the plan of care and targeted length of stay with the multidisciplinary team, patients, and family at the time of admission.
• Explores strategies to reduce the length of stay and resource consumption.
• Serves as a patient advocate with the health care team, payors and outside agencies.
• Collaborates with primary nurses to identify plans to maintain streamlined patient care.
• Participates in the daily discharge rapid rounds (multidisciplinary team meetings) coming prepared with essential information.
• Identifies a plan with the Case Management Director and/or Team Leader to address system opportunities and participates in that plan.
• Communication Competencies
• Communicates patient needs to medical staff, nursing staff, Case Management team, as appropriate.
• Communicates patient needs, with attention to details, to service providers to insure safe level of care and appropriate resources after discharge.
• Communicates with medical staff regarding case management issues as they occur and document in Soarian Clinicals.
• Communicates with ancillary departments to negotiate accelerated test scheduling to receive results not yet available on medical record in Soarian Clinicals, or ensure interaction with patient as ordered by physician.
• Documentation Competencies
• Records all patient/family activity, interaction or intervention related to discharge planning on the medical record using the Soarian Clinical system.
• Documents action taken related to discharge planning within same day of interaction with patient/family and/or physician.

Credentials:

Education or Equivalent Experience:

• Bachelor of Arts or Science (Required)
• 0-1 years Discharge planning experience