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Current Open Position for Which You Are Applying:

Social Services/Discharge Planning

Job Description

POSITION SUMMARY:      

             Under the general direction of the Director of Case Management, the SW/Discharge Planner will begin initiating a discharge disposition on the day of admission by following the criteria listed below, and will follow the patient until the final discharge to promote a smooth transition of care.

 

EDUCATION/EXPERIENCE/SKILLS:

             This position requires a licensed Social Worker at a Bachelor Level, as a minimum. The candidate must have at least 2 years of Medical Social Services experience.

 

ESSENTIAL DUTIES/TASKS/RESPONSIBILITIES:

The Social Worker will serve in the role of Social Worker/Discharge Planner. They will visit and assess the patient within 24 hours of admission and will complete a Case Management Set (CMS) to aid in choosing an appropriate Discharge Disposition. . Each new admission will either be assigned to an RN/DP or a SW/DP. Both have the job description of discharge planning.

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  • The findings will then be entered under Interventions as a working discharge disposition that can be accessed by all departments

     

  • They will continue to monitor the patient in following days for appropriate care, utilization of resources, and the need for transition between levels of care.

     

  •  They will work to develop an appropriate discharge plan for patients of all ages based upon patient needs, available resources and the patient/families choices.

 

  • They will respect the patient’s Privacy and Rights as required by The Joint Commission

                               

  • If it is determined that the patient needs continued services post discharge, the Discharge Planner (SW or RN) will provide the patient with information regarding the choice’s that are available to meet their needs. A choice form will be given so that the patient can have a personal choice, and once that form is signed, it will become part of the patient’s permanent medical record indicating their choice.

     

  •  Based on the severity of the patient’s needs will determine if the Social Worker is assigned to the patient or if the RN Discharge Planner will work on securing a final discharge disposition.

     

  • If the Social Worker receives a consult for an at-risk patient that is generated by the nursing/and or medical staff they will perform a psychosocial assessment through review of the medical chart, interviews with the patient/ and or family, medical staff, and/or physician, and will document findings by way of a Social Service Consult note in the EMR.

     

  • SW/DP will document all work performed, including assessment, interventions, progress of patient, and family’s understanding of situation and actions to be taken

  •  SW/DP will collaborate with medical and hospital staff and various departments and coordinate Case Care Conferences if applicable

                 

  • SW/Discharge Planners are able to prioritize work level and complete assigned tasks in an accurate, complete, and timely manner.

     

  • SW/DP is able to use professional judgment and decision making skills when relating to patients and/or families.

     

  •  SW/DP will demonstrate a sensitive and supportive attitude.

     

  • SW/Discharge Planners handles crisis situations and counseling to patients regarding adjustment to illness  

     

  • SW/DP Reviews patients’ progress along clinical pathway, if applicable

     

  • SW/DP Monitors timeliness of testing and completion of orders, including ancillary consults

     

  • SW/DP Facilitates transfer of patient to appropriate post-hospital setting, i.e. Skilled Nursing Facilities, Extended Care Facilities, Rehabilitation Centers, or Home Health Care as well as DME if applicable.

     

  • SW/DP Maintains ongoing verbal communication with patient and/or family, physician, Nursing and other interdisciplinary teams regarding discharge planning

               

  •  SW/DP demonstrates the ability to work with a variety of patients regardless of racial, ethnic, sociological backgrounds, medical diagnosis, disability or age

     

  • SW/DP seeks supervisory guidance as necessary

     

  • SW/DP demonstrates the ability to assess a situation from a variety of perspectives, consider alternatives, and chooses an appropriate course of action.

                 

  • Procures pastoral assistance when requested by the patient and family

 

  • This is a general explanation of the job description, but certainly doesn’t cover the full scope. They could be asked by their Supervisor to assist in another manner.

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