Social Worker Discharge Planning

Northwestern Memorial Healthcare•DeKalb, IL

About The Position

The Social Worker Discharge Planning provides high-quality services throughout the continuum of care to patients and their families, supporting optimal social and emotional functioning. The role provides direct services on an inpatient and outpatient basis and coordinates care options and services in collaboration with physicians and other healthcare personnel. The Social Worker supports safe, effective transitions and comprehensive discharge plans, while adhering to Northwestern Medicine’s mission, values, Code of Ethics, compliance requirements, policies, and applicable regulatory and accreditation standards. The position assesses and coordinates patients’ discharge needs, collaborates with patients, families, and interdisciplinary teams on plans of continuing care, supports progression of care, and helps ensure services align with patient goals and available financial resources. It provides patient and family education, connects people with community and other resources, supports utilization management, and responds to specified hospital emergencies when present. The role also maintains appropriate documentation and helps ensure compliance with applicable laws and organizational policies.

Requirements

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

Responsibilities

Coordinate discharge planning and social services, identifying patients who may need services after discharge and considering 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 among providers, and improvement in patient care.
Implement practice changes based on utilization review and utilization management benchmark findings.
Support compliance with mandated Medicare and Medicaid initiatives.
Serve as a hospital and community resource for locating appropriate services.
Promote patient safety by identifying patients at high risk for discharge-service needs, 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 other applicable healthcare laws.
Work with patients, families, and the healthcare team to develop continuing-care plans that reflect patient needs, goals, and financial resources.
Document care and plans in Meditech, Midas, and the patient record as required; complete forms required by the Illinois Mental Health Code.
Support family or significant-other participation in care according to the patient’s request or approval.
Participate in interdisciplinary communication and conferences to formulate, implement, evaluate, and revise patient-specific plans of care.
Help patients and care teams progress toward goals and anticipated discharge dates.
Collaborate with the interdisciplinary team on transitions to lower levels of care, ancillary services, discharge, less expensive treatment alternatives, and education as appropriate.
Identify potential avoidable days, collaborate with physicians and nursing staff to address them, and document them in MIDAS.
Respond to insurance reviews and requests in a timely manner; complete insurance pre-certification for psychiatric transfers and durable medical equipment as needed.
Support organizational resource-utilization goals, including serving as a resource on mental health laws and psychiatric services, supporting staffing appropriate to census and patient needs, and identifying cost-saving measures.
Anticipate barriers to patient progress and continually assess discharge needs and changes in those needs.
Coordinate transfers to hospitals with appropriate psychiatric facilities as ordered by a physician or psychiatrist or requested by the patient or family, in accordance with EMTALA, COBRA laws, and hospital policies.
Provide referrals based on financial needs and funding.
Educate patients about discharge planning, options, resources, utilization management, and advance directives, taking into account learning needs, abilities, preferences, and readiness and supporting informed decision-making.
Provide information about services available in the surrounding community and help people locate resources in more distant areas.
Respond to Code 999 when present in the hospital, assist with de-escalation of behavioral patients, and support medical staff in maintaining patient safety, including restraints as needed; document interventions and debriefing.
Respond to Code Blue and Rapid Response when present in the hospital, support communication with and services for family members, contact family by phone with medical-status information, and help coordinate resources such as housing or local services; document interventions and services provided.
Recognize, respond to, and appropriately refer requests for problem intervention, including matters under the Illinois Mental Health and Developmental Disabilities Code.
Serve as a resource to patients, the community, and the interdisciplinary team regarding mental health laws and advance directives.