Job Responsibilities • Perform a comprehensive psychosocial assessment when triggered to identify the patient's health goals and coordinate services with the RN Case Manager for an effective transition plan. Meets directly with patient/family on an ongoing basis as identified. • Identify the need for patient/family regarding Social / Psychosocial issues that need to be addressed. • Build on the discharge planning assessment in developing, coordinating, implementing and revising a care plan to ensure good transition management and continuity of care (LOS, discharge delays), cost reduction and patient self-management (patient activation). • Collaborates with the physician and all members of the multidisciplinary team to facilitate care and assist in meeting discharge goals. • Completes assigned goals. • Provides supportive counseling to individuals, families, and groups to address identified concerns and to enhance understanding of coping with and adjustment to illness/hospitalization.
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Job Type
Full-time