Discharge Planner - Social Service Coordinator

HHC•Indianapolis, IN

61d•Onsite

About The Position

Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 333-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus including at a network of Eskenazi Health Center sites located throughout Indianapolis. The Discharge/Planner Social Service Coordinator is responsible for providing comprehensive social services which assist patients, clients and their families to find practical ways of overcoming social, emotional and environmental barriers to optimum functioning and attainment of health. The Discharge/Planner Social Service Coordinator alters activities/behaviors to reflect and ensure adequate care and services appropriate to the age of patients served (i.e. neonatal, infant, pediatric, pre-school, school age, adolescent, adult, geriatric).

Requirements

Minimum of a Master's of Social Service or related field degree including but not limited to a MSW
Effective communication skills
Knowledge and skills necessary to provide care appropriate to the age of patients served. Must demonstrate knowledge of growth and development principles over the life span and possess the ability to assess data/interpret appropriate information needed to identify each patient's requirements relative to age-specific needs. Ability to use age appropriate communication and skills detailed in the department/area/unit job specific/age specific competencies
Analytical, psychosocial assessment and counseling skills
Knowledge of pertinent State/Federal laws and regulations, community systems and resources
Ability to work cooperatively with multi-discipline teams in situations requiring a high degree of flexibility, creativity, initiative
Ability to apply social service techniques/principles including evaluation, intervention, and case management
Ability to perform duties independently under the direction of specified supervisor
Ability to recognize own limitations and seek assistance from appropriate resources as needed

Nice To Haves

Social service experience in a healthcare setting dealing with pediatric, adolescent, adult and geriatric patients is preferred

Responsibilities

Interviews hospital patients and their families during the course of an inpatient or observation admission
Responsible for managing assignment of specified unit or clinic, ensuring that 100% of patients with an identified need have been assessed and evaluated
Initiates social service plans for patients/clients through professional collaboration with medical, nursing and health care personnel utilizing screening questionnaires, diagnostic assessments and individualized therapeutic care plans
Coordinates the overall interdisciplinary plan of care for a patient from admission to discharge
Serves as a liaison between patient/family and healthcare personnel to ensure necessary care is provided promptly and effectively
Coordinates discharge plans to meet the patients social and emotional needs to ensure a safe and effective discharge
Assists patients and families in understanding the implications and complexities of their medical situation and its impact on their current lifestyle
Provides direction in the selection, analysis, summarization and presentation of patient/client and related information for service delivery planning, case conferences and professional consultation
Provides complex social service intervention to individuals, families and groups ranging from diagnostic assessment, short term counseling, crisis intervention, community resource referrals, client advocacy, support, outreach, follow-up and intra/inter agency consultations
Provides education and training to introduce or improve coping skills of individuals and families
Documents services rendered in clinical records
Responsible for following the required assessment format to ensure all elements for effective discharging have been met with the ultimate goal of reducing readmissions
Responsible for partnering with the multidisciplinary team to ensure financial resources have been assessed and a determination made to ensure there are limited placement barriers post discharge
Conducts social service orientation for physician, nurses, and students as appropriate
Utilizes problem-solving skills to identity and facilitate problem resolution in team functioning
Participates in staff meetings and education programs for staff and community agencies as assigned
Assumes responsibility for continuous professional self-development
Alters activities/behaviors to reflect/ensure adequate care appropriate to the age of patients served (i.e. adolescent, geriatric, pediatric, neo-natal, adult) described in the area/unit age-specific and/or job specific competencies
Collaborates with multi-disciplinary team members to facilitate the coordination and deliver) of services that assures appropriate treatment plans and continuity of care
Initiates advocacy/liaison role for patients/clients in referrals to and from community agencies: collaborates with agency and hospital personnel in referral activities: cultivates referral resources
Interprets impact on client functioning of environmental conditions and family interactions through home visits and outpatient encounters