Job Specific Competencies: Provides for the discharge planning of patients to ensure continuity of care and discharge to the least restrictive setting. Identifies "high risk" patients in order to provide social work services and complex discharge planning needs. Interviews patients, families and/or community support services to assess patients' psychological, social, environmental and financial status and meet identified needs. Participates in Interdisciplinary Discharge Planning Rounds to assess discharge planning needs, identify problems and communicate on-going interventions. Engages patients and families in decision making necessary during hospitalization treatment, including but not limited to discharge planning treatment decisions. Provides crisis intervention services to patients and families to enable them to cope with the end of life issues, adjust to new and/or chronic illness, as well as, catastrophic events, which impact their lives. Educates patients and/or families about discharge planning, patient needs, as well as availability and eligibility criteria for programs/services benefits to meet those needs. Creatively negotiates, coordinates, and advocates community based services (DYFS, APS, Office of Public Guardian, DDD, etc.) to assure continuation of care and special services appropriate to the age of patients and needs identified. Helps people anticipate delays or changes by keeping them informed of progress. Documents in the Medical Record all assessments, reassessments and interventions to enhance multidisciplinary communications, as well as, to meet all regulatory and reimbursement standards. Maintains appropriate case folders, resource files and statistical reports to facilitate monitoring and evaluations. When deficiencies are identified assists in initiating corrective actions. Monitors discharge planning delays to identify and report trends for performance improvement. Attends appropriate Social Work conferences/workshops to maintain CEUs and license specific requirements.
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Number of Employees
5,001-10,000 employees