Disposition Planner @ Cobb Hospital

Wellstar Health System•Austell, GA

1d•Onsite

About The Position

The Care Coordinator is responsible for coordination of care for every patient from the time of admission until discharge from the hospital to the next level of care. This includes psychosocial and functional status assessment, individual, group and family therapy sessions, transitional care planning, patient advocacy, education for the patient/family, and assuring a safe and adequate discharge plan depending upon the patient's needs and resources. Collaborates with all team members to provide a comprehensive assessment of the patient's plan of care, goal/outcome attainment and continued care needs.

Requirements

Master's Degree in Social Work or Counseling
Lic Clinical Social Worker GA or Lic Master Social Worker in GA or Master Social Worker or Registered Nurse (RN)
Minimum of one year of clinical practice/experience in general medical-surgical or behavioral health setting
Organizational and professional communication skills
Ability to facilitate process groups with the patient population
Ability to act as a liaison with multidisciplinary team members

Responsibilities

Initiate and interpret thorough clinical assessments, considering age and developmental needs when developing discharge and resource plans.
Determine mental status, history of present illness, financial status, living situation, support system, and risk of harm to self or others.
Understand and be sensitive to the developmental needs of adult and geriatric populations in assessment and care planning.
Assist families with placement of patients in supervised living arrangements.
Recommend appropriate level of care and facilitate access to services (inpatient, outpatient, residential).
Consult with Physicians, Providers, and treatment team members regarding behavioral health services.
Review criteria and scope of services with patient/guardian for comprehension and provide recommendations.
Recognize indicators of suspected child/adolescent/disabled person/elder abuse and neglect, and follow mandated reporting policies.
Document psychosocial assessment information in the electronic medical record.
Partner with patient and family/support system to develop treatment plans based on needs (education, support, case management).
Implement discharge planning in an appropriate, timely, and efficient manner.
Attend multidisciplinary team meetings and care plan meetings to assist with disposition planning.
Serve as patient advocate in the recovery/healing process.
Provide resource information for patient/family follow-up care plans.
Understand eligibility processes for private and public local, state, and federal resources.
Complete necessary paperwork (including continuing care plan) and arrange for transfer to appropriate level of care.
Evaluate the effectiveness of the patient's plan of care and make revisions as needed.
Provide education and counseling for patients and families; provide individual and group therapy; document interventions.
Develop and maintain productive working relationships with community agencies, nursing homes, personal care homes, and other resource centers.
Demonstrate working knowledge of community resources.
Respond to requests from hospital staff, provider offices, and community entities for resource information and education.
Provide financial needs assessment and make appropriate referrals for patients needing assistance.
Provide follow-up for patients needing post-discharge assistance.
Provide crisis intervention for patients and families.
Understand pre-certification processes for acquiring services (DME, home health, SNF).
Negotiate and refer for services outside of patient's health plan, in collaboration with UR.
Interface with DFACS, APS, and other state regulatory agencies as needed.
Assist with patient/family complaint resolution and service recovery.
Complete and document initial psychosocial/functional assessment in the electronic medical record.
Document evaluation, treatment plan, ongoing reassessments, and safety plan.
Document outcomes of every group therapy session.
Document each patient contact regarding discharge plans and anticipated level of care.
Document interactions with family/support systems.
Assist with legal documentation as needed for patient placement.
Adhere to ethical business practices and highest standards of ethical behavior, integrity, and honesty.
Embrace diversity and demonstrate ability to work together.
Maintain confidentiality of all patient information.
Maintain attendance/punctuality.
Adhere to departmental dress code policy.
Communicate information effectively both verbally and in writing.
Attend and participate in staff meetings, required inservices, process improvement activities, and other meetings.
Organize workload to complete responsibilities in an appropriate and timely manner.
Utilize materials and equipment in a safe and cost-effective manner.
Observe infection prevention precautions.
Strive to help lead the industry through vision, technology, innovation and customer service.
Strive to make a difference in the lives of employees and patients.
Consistently apply AIDET principles in all interactions with patients.
Encourage a positive environment and experience for co-workers and patients.
Treat patients and fellow team members with respect.
Foster teamwork with trust, support, and collaboration.
Demonstrate knowledge of service recovery principles and implement appropriately.
Participate in professional development and mandatory education activities.
Complete core and annual competencies.
Complete all educational requirements required by discipline to maintain licensure.
Participate in orientation and training of new employees.
Complete all mandatory hospital and/or system mandatory requirements.