Discharge Coordinator (Social Services)

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, complete admission paperwork, and explain Social Services role and begin 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.

SUPERVISORY RESPONSIBILITIES

None

QUALIFICATIONS

• Social Service Designation preferred
• Willingness and capability to obtain Social Service Designation required
• Must pass a criminal background check.

EDUCATION AND EXPERIENCE

Social Work degree preferred.

PHYSICAL DEMANDS

1. Physical

a. Will need to be able to stand and sit for extended periods, bend, twist, and reach to the floor. 

2. Sensory

a. Must be able to receive and follow verbal and written instructions. 

b. Must be able to respond to audible emergency signals, alarms, call lights, and telephones. 

c. Must be able to read regular/small-size print in multiple colors. 

3. Cognitive 

a. Must be able to remember multiple assignments over an extended period. 

b. Be able to remember data derived from assessments and documents, review, specific requests, ideas, and concepts, and relate them as necessary. 

c. Must be able to concentrate on details during constant interruptions.

Equipment used: Writing implements, computer, calculator, fax machine, telephone call systems, photocopier, and other equipment as necessary.

WORK ENVIRONMENT

Works primarily indoors in a climate-controlled setting. There is the potential for exposure to blood, body tissues, and fluids with occasional exposure to hazardous materials and infectious diseases. Exposure to chemicals is occasional. There is known stress associated with working with patients who are ill, confused, irritable, or irrational.

QUALIFICATIONS

Social Service Designation preferred

Willingness and capability to obtain Social Service Designation required

Must pass a criminal background check.

EDUCATION AND EXPERIENCE

Social Work degree preferred.

PHYSICAL DEMANDS

1. Physical

a. Will need to be able to stand and sit for extended periods, bend, twist, and reach to the floor. 

2. Sensory

a. Must be able to receive and follow verbal and written instructions. 

b. Must be able to respond to audible emergency signals, alarms, call lights, and telephones. 

c. Must be able to read regular/small-size print in multiple colors. 

3. Cognitive 

a. Must be able to remember multiple assignments over an extended period. 

b. Be able to remember data derived from assessments and documents, review, specific requests, ideas, and concepts, and relate them as necessary. 

c. Must be able to concentrate on details during constant interruptions.

Equipment used: Writing implements, computer, calculator, fax machine, telephone call systems, photocopier, and other equipment as necessary.

WORK ENVIRONMENT

Works primarily indoors in a climate-controlled setting. There is the potential for exposure to blood, body tissues, and fluids with occasional exposure to hazardous materials and infectious diseases. Exposure to chemicals is occasional. There is known stress associated with working with patients who are ill, confused, irritable, or irrational.