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. Services may be provided on an inpatient or outpatient basis. The Social Worker coordinates care options and services by collaborating and consulting with physicians and other healthcare personnel, and adheres to Northwestern Medicine’s mission, values, Code of Ethics, compliance program, policies, procedures, and applicable regulatory and accreditation standards.

The role coordinates discharge planning and social services, identifies patients who may need post-discharge assistance, and supports safe, comprehensive transitions of care. The Social Worker works with patients, families, physicians, and interdisciplinary teams to establish and document care plans, support progression toward anticipated discharge dates, address barriers and avoidable days, and coordinate appropriate services and resources. The position also supports utilization management, insurance reviews and pre-certifications, psychiatric transfers, patient education, community referrals, and responses to hospital emergency codes when present.

Requirements

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

Responsibilities

• Coordinate discharge planning and social services, identifying patients who need services after discharge while 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 performance improvement in patient care.
• Implement practice changes based on utilization review and utilization management benchmark findings.
• Ensure compliance with mandated Medicare and Medicaid initiatives.
• Serve as a hospital and community resource to help people find appropriate services.
• Promote patient safety by identifying patients at high risk for 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.
• Work with patients and families to develop continuing-care plans aligned with patient needs, goals, and financial resources; document plans in Meditech and Midas.
• Support family or significant-other participation in care when requested or approved by the patient.
• Complete required forms under the Illinois Mental Health Code.
• Participate in interdisciplinary communication and conferences to formulate, implement, evaluate, and revise patient-specific plans of care, and document care appropriately.
• Support progression of care by helping patients, families, and interdisciplinary teams work 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 patient education when 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, and document insurance information in Meditech and/or MIDAS and 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 progress toward goals and continually assess for discharge needs or 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 availability.
• Provide ongoing education by assessing learning needs, abilities, preferences, and readiness; explaining discharge planning, options, resources, utilization management, and advance directives; and supporting informed decision-making.
• Provide information about services and care available in the local 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 assist medical staff in maintaining patient safety, including restraints as needed.
• Document interventions during Code 999, including restraints and debriefing with medical staff.
• Respond to Code Blue and Rapid Response when present in the hospital; provide communication and support to family members, including contacting family by phone about current medical status when appropriate.
• Help medical staff coordinate resources for families, including housing or local services, and document interventions and services provided during codes.
• 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 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 against unexpected life events

What This Job Offers

• Job Type: Full-time