Discharge Planner

Reid Health

9d•Onsite

About The Position

The Discharge Planner coordinates patient transition along the healthcare continuum through assessments, referrals and interdisciplinary planning. Coordinates the posthospitalization services as outlined in the patient’s transition plan. The Discharge Planner provides the necessary focus on the patient’s psycho-social, financial, and transition needs in order to promote optimal outcomes including reducing related and unplanned re-hospitalization. Refers patients to appropriate community services and resources. Alerts members of the interdisciplinary team to psycho-social and financial issues risk factors. The Discharge Planner applies the use of data in his/her practice; identifying where to focus efforts, the measurement of progress towards identified outcomes, and as an educational tool.

Requirements

Bachelor's degree in Social Work or equivalent field.
1 year of experience in a healthcare setting as a social worker or equivalent field.

Nice To Haves

Master's degree in Social Work or equivalent field.
3-5 years experience in healthcare setting as a social worker or equivalent field.

Responsibilities

Works collaboratively with the Case Manager and interdisciplinary team to identify and establish patient transition plans and coordinates a timely, safe patient discharge/transfer.
Coordinates post-hospitalization services for patients as identified by the interdisciplinary team.
Understands the patient’s planned course of treatment to the degree necessary in order to anticipate “transition readiness” and coordinate a timely discharge/transfer.
Starts referrals timely to ensure the payer authorization process can begin early and avoid delays, as applicable.
Collaborates with the patient/family in the selection and making of post-hospitalization care arrangements; offers patients a choice of vendors. Discloses which vendors have a financial relationship with the hospital and documents both; follows Transition Management Policy.
Keeps the patient/family, Case Manager, and healthcare team well informed.
Communicates the relevant information to the agency/facility that will assume responsibility for continuing care after the patient’s release and documents as such.
Documents all transition coordination activities and interventions in the medical record.
Makes referrals to other department services as applicable to the patient’s needs to expedite a safe and timely discharge.
Trends, analyzes, and reports outcomes, clinical process, and variance data to appropriate audiences.
Participates in process and outcome improvement activities and helps facilitate approved practice changes.
For the assigned population, attends appropriate physician and Nurse Leader meetings to report on trends, outcomes, and statistics. Receives and acts on feedback from physicians and nursing management related to Discharge Planning.
Participates in all appropriate and/or required hospital-wide progress activities and efforts.
Performs other duties as assigned to accomplish the goals of the organization.