Social Worker Discharge Planning

Northwestern Memorial Healthcare • DeKalb, IL

4d

About The Position

The Social Worker Discharge Planning provides high-quality services throughout the continuum of care to patients and their families to support optimal social and emotional functioning. Services include direct inpatient and outpatient support. The role coordinates care options and services in collaboration with physicians and other healthcare personnel, supporting safe transitions, patient-centered plans of continuing care, and appropriate resource use. The Social Worker also serves as a hospital and community resource for patients, families, and staff, including guidance on mental health laws and available services.

Requirements

• Bachelor’s degree in Social Work.
• At least two years of hospital experience in discharge planning, with documented experience providing direct services to patients in an acute care setting.
• Knowledge of normal characteristics of growth and development throughout the lifespan.
• LCSW.

Responsibilities

• Coordinate discharge planning and social services, identifying patients who may need post-discharge services and considering normal growth and development across the lifespan.
• Collaborate with medical staff and the healthcare team to support smooth transitions and comprehensive discharge plans for patients and families.
• Monitor clinical information to support assessment, treatment, education, continuity of care, and performance improvement.
• Implement practice changes based on utilization review and utilization management benchmark findings; support compliance with Medicare and Medicaid initiatives.
• Promote patient safety through identifying patients at risk of needing discharge services, using SBAR and closed-loop communication, following national patient safety goals, and maintaining infection control standards.
• Protect client rights in accordance with the Illinois Mental Health Code and applicable healthcare laws.
• Collaborate with patients, families, and the healthcare team to develop continuing-care plans compatible with patient needs, goals, and financial resources; document plans and care in Meditech and MIDAS as appropriate.
• Complete required forms under the Illinois Mental Health Code and participate in interdisciplinary communication and care conferences to formulate, implement, evaluate, and revise patient care plans.
• Support progression of care by aligning the patient, family, and interdisciplinary team around goals and anticipated discharge dates.
• Work with the interdisciplinary team to address lower levels of care, ancillary services, discharge, less expensive treatment alternatives, and patient education as appropriate.
• Identify potential avoidable days and work with physicians and nursing staff to address them; document avoidable days in MIDAS.
• Respond to insurance reviews and requests promptly; complete insurance pre-certification for psychiatric transfers and durable medical equipment as needed, and document insurance information in Meditech and/or MIDAS.
• Support organizational resource-utilization goals by advising physicians and hospital staff on mental health laws and psychiatric services, supporting staffing suited to census and patient needs, and identifying cost-saving measures.
• Assess patients on an ongoing basis to anticipate barriers to progress and identify discharge needs or changes in those needs.
• Coordinate transfers to hospitals with appropriate psychiatric facilities when ordered by a physician or requested by the patient or family, in accordance with EMTALA, COBRA, and hospital policies.
• Provide referrals based on financial needs and available funding.
• Educate patients about discharge planning, options, resources, utilization management, and advance directives, taking account of learning needs, abilities, preferences, readiness, and informed decision-making.
• Help patients and others find information about services and care available locally or in distant areas.
• Respond to Code 999 when present in the hospital, assist with de-escalation of behavioral patients, and support staff in maintaining patient safety, including restraints when needed; document interventions and debriefing.
• Respond to Code Blue and Rapid Response when present, support family communication, contact family by phone with current medical-status information, help coordinate resources such as housing or local services, and document interventions.
• Recognize, respond to, and appropriately refer requests for problem intervention under the Illinois Mental Health and Developmental Disabilities Code; serve as a resource on mental health laws and advance directives.

Benefits

• Tuition reimbursement
• Loan forgiveness
• 401(k) matching
• A wide range of benefits supporting physical, emotional, and financial well-being and protection from unexpected life events

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level