Discharge Planner

PURPOSE STATEMENT

Collaborates with the Case Management department to assist in facilitating appropriate post-acute patient placement, utilizing hospital and community resources for continuity of patient care.

ESSENTIAL FUNCTIONS  

• Assist with initial discharge planning assessment of patient population, establishing patient and family needs post discharge.
• Assist with post-acute patient placement and discharge needs, including but not limited to skilled nursing facility referrals, arrangements for transportation, home medical equipment, home infusion therapy, hospice referrals and home health services.
• Facilitate the second issuance of the Important Message for all Medicare patients and document issuance in the patient record.
• Identify patients in need of assistance in acquiring medications for post-acute care and make arrangements for procurement.
• Participate in multidisciplinary team rounds for review of patient’s plan of care, discharge planning and utilization management, collaborating with team members to address patient needs and desired outcomes.
• Provide patient/family with information about post hospital care placement options, ensure patient choice and obtain necessary consents to refer patient to appropriate facility/services.
• Maintain expertise regarding community resources.
• Advocate for the patient and family throughout the entire episode of care, maintains availability to the patient/family as a resource to facilitate communication among providers and enables patient/family to make informed decisions.
• Assist with documentation and capturing department metrics as directed by the UM Plan (i.e. avoidable days, delays, interventions, etc.).
• Display a high level of flexibility, adaptability, and organizational skills in response to the workload and effectively prioritize work while maintaining productivity.
• Cooperate with changes in staffing schedules to achieve department productivity standards.
• Participate in department-based Performance Improvement activities.
• Participate in department activities and provide input when appropriate.
• Contribute to the development of competencies related to job functions and participate in competency evaluations.
• Demonstrate attendance patterns to reflect commitment to the job requirements and patient care needs.
• Demonstrate a working knowledge of HIPAA guidelines and utilize them in all aspects of communication with patients and families.
• Maintain regular and predictable attendance.
• Perform other essential duties as assigned.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS 

• High school diploma or equivalent.
• Bachelor’s degree in Social Work or similar field required.
• Licensed Clinical Social Worker (LCSW) or Licensed Master Social Worker (LMSW) preferred.
• Current AHA or Red Cross BLS required.
• 1-3 years hospital based acute care experience preferred.
• Ability to work independently as well as take direction.
• Strong written and verbal skills.
• Effective interpersonal skills.
• Must be self-motivated and have the ability to work within the established policies, procedures and practices prescribed by the hospital/clinic.

PHYSICAL/MENTAL REQUIREMENTS

• Must be able to sit and stand, intermittent 8 to 10 hours a day.
• Must be able to use standard office equipment, including the telephone and computer keyboard.
• Continuously works under pressure of near 100% accuracy while meeting inflexible deadlines.
• Continuously utilizes manual/bi-manual dexterity, near vision, speech, and hearing.