Social Worker Discharge Planning

Northwestern Memorial Healthcare • DeKalb, IL

2d • $31 - $46

About The Position

The Social Worker Discharge Planning provides high-quality services across the continuum of care to patients and their families to support optimal social and emotional functioning. The role provides direct services in inpatient and outpatient settings and coordinates care options and services in collaboration with physicians and other healthcare personnel. The Social Worker supports safe, comprehensive transitions and discharge planning while complying with Northwestern Medicine policies, professional ethics, applicable laws, and regulatory and accreditation standards.

The position assesses patient and family needs, develops and documents plans of continuing care, supports patient education and informed decision-making, and coordinates community and healthcare resources. It also contributes to utilization management, resource stewardship, insurance reviews and pre-certifications, and timely progression of care. When present in the hospital, the Social Worker responds to emergency codes and assists with communication, supportive services, de-escalation, and coordination of resources.

Requirements

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

Responsibilities

• Coordinate discharge planning and social services, identifying patients who may need services after discharge.
• Collaborate with medical staff, patients, families, and other healthcare team members to develop and implement comprehensive plans of continuing care and smooth transitions.
• 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 and applicable patient-rights laws, including the Illinois Mental Health Code.
• Act as a hospital and community resource for patients and others seeking appropriate services, including services in distant areas.
• Promote patient safety by identifying patients at high risk for discharge assistance, using SBAR and closed-loop communication, following national patient safety goals, and maintaining infection-control standards.
• Coordinate care activities with patients to meet their goals, document plans and care in Meditech and Midas, and complete required forms under the Illinois Mental Health Code.
• Support family or significant-other participation in care as requested or approved by the patient.
• Participate in interdisciplinary communication and conferences to formulate, implement, evaluate, and revise patient-specific plans of care.
• Support progression of care by helping the patient, family, and interdisciplinary team work toward goals and the anticipated discharge date.
• Collaborate with the interdisciplinary team on transitions to lower levels of care, ancillary services, discharge decisions, less expensive treatment alternatives, and patient education when appropriate.
• Identify potential avoidable days, work 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 and document insurance information in the patient record.
• Support organizational resource-utilization goals by advising physicians and staff about 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 for discharge needs or changes in those needs.
• Coordinate patient 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, tailoring education to learning needs, abilities, preferences, and readiness and supporting informed decisions.
• Respond to Code 999 when present; assist with de-escalation of behavioral patients and patient safety measures, including restraints as needed, and document interventions, restraints, and debriefing with medical staff.
• Respond to Code Blue and Rapid Response when present; communicate with and support family members, contact family by phone about current medical status, coordinate resources such as housing or local services, and document interventions and services.
• Recognize, respond to, and appropriately refer requests for problem intervention in accordance with the Illinois Mental Health and Developmental Disabilities Code.
• Serve as a resource to patients, the community, and the interdisciplinary team on mental health laws and advance directives.

Benefits

• The company describes a range of benefits intended to support employees’ physical, emotional, and financial well-being and provide protection against unexpected life events.
• Tuition reimbursement.
• Loan forgiveness.
• 401(k) matching.
• Lifecycle benefits.

What This Job Offers

• Job Type: Full-time