Discharge Coordinator

Description

SUMMARY

A Medicare social worker takes on many roles. They are patient advocates and counselors, perform psychological assessments, refer patients and families to medical resources, and provide patient and family assistance in obtaining financial and legal assistance. Most importantly, a medical social worker works to ensure that the best interests of the patient are being met.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Discharge Planning

Patient & Family Member Advocate

Interdisciplinary Teams

Admissions

· Meet and greet all new patients and families, explaining Social Services role and establishing discharge goals.

· Complete electric lift chair and elopement assessments within 72 hours of admission.

· Complete social service and MDS assessments including BIMS and PHQ 9 assessments and write a progress note within the necessary timeframe to meet Medicare guidelines.

· Complete CAA’s necessary for MDS process on 5-day admission MDS’s. 

· Identify problems indicated by CAA’s and establish care plans to address each problem as indicated on the MDS.

Ongoing Responsibilities and Specialties

· Identify problems and changes in conditions with patients, by developing a relationship with patients, encouraging the patient to be comfortable with the Social Worker and trust, and assuring confidentiality with each interaction.

· Provide counseling with family members and Medicare patients as needed, when particular mood states or behavior problems arise. 

· Contact psychiatric services when necessary for patients, after receiving signed consents from either patient or family. Fax the necessary documentation to the psychologist necessary to begin services.

· Crisis Intervention and Inpatient Hospitalizations- provide interventions with patients when needed during behavior outbursts or mood state crises. Make necessary arrangements for inpatient care or treatment needed for the well-being of the PHC patient.

· Make necessary arrangements as needed for transfers when determined appropriate by the administration. Follow through with referrals, assessment processes, and transportation of patients to alternate facilities.

Patient Advocate

· Serve as an advocate to patients and families, documenting concerns and resolving complaints.

· Schedule interdisciplinary meetings as needed, to resolve family concerns.

· Be available to families and patients to provide information and referrals to community services for financial and other needs.

· Make referrals to the Ombudsman or Adult Protective Services and or Sherriff when appropriate.

Discharge Coordinator

· Provide Discharge planning to patients.

· Schedule care plan meetings with patients and their families to discuss necessary goals, referrals, and DME necessary for a safe discharge.

· Provide necessary resources to the patients and families for any needed community services.

· Provide referrals to Home Health Care, Hospice agencies, Home Medical Equipment, Thrive, and/or private pay agencies for discharge planning.

· Complete necessary documentation for discharges and referrals. 

· Complete necessary discharge MDS documentation.

· Complete necessary documentation regarding ongoing progress, special circumstances, or problems throughout the patient’s rehabilitation.

Interdisciplinary Team Member

· Serve as an interdisciplinary team member by attending designated meetings.

· Maintain Behavior Logs and interact with staff to ensure that behavior logs are current and completed.

Requirements

QUALIFICATIONS

Must obtain or possess a Social Service Designation. 

Must pass a criminal background check.

EDUCATION AND EXPERIENCE

Social Work degree preferred.