POSITION SUMMARY

The Social Worker/Discharge Planning Coordinator intervenes with patients who are psychosocially complex, have Social Determinants of Health (SDOH) needs, and/or require assistance with transitions of care or discharge planning. In addition, the Social Worker/Discharge Planning Coordinator offers supportive intervention (i.e., trauma, terminal diagnosis, mental health etc.) to patients and caregiver(s) and coordinates and facilitates the development of a discharge plan of care for high-risk/complex patient populations. They may self-refer or receive referrals for patients from interdisciplinary team members and are responsible for collaborating with the care team (Physicians, Nurses, RN Acute Care Navigators, Care Navigation Coordinators, Contracted Vendors, etc.) and escalating appropriately to ensure their assigned patients receives exceptional care and avoid unnecessary delays in care or discharge.

ACCOUNTABILITIES

*All duties listed below are essential unless noted otherwise*

1. Psychosocial Assessment and Interventions:

a. Assesses patient’s and caregiver’s psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope.

b. Intervenes with patients and caregivers regarding emotional, social, and financial consequences of illness and/or disability; accesses and provides caregiver(s)/community resources to meet identified needs.

c. Serves as a resource to provide information and intervention related to treatment decisions and end-of-life issues.

d. Advocates for patient and caregiver empowerment and independence to make autonomous health care decisions and access needed services within the healthcare system.

e. Documents all findings in the electronic medical record (EMR).

f. Develops therapeutic relationships and obtains psychosocial and SDOH information necessary for the facilitation of appropriate discharge planning.

2. Identifies patients most at risk for readmission without intensive discharge planning through information gathered on the admission nursing database, EMR predictive analytics tools, and proactive case finding.

3. Assesses inpatients to determine ability for self-care and to identify those most at risk for post-discharge adverse health consequences without intensive discharge planning.

4. Complex Discharge Planning:

a. Participates in supporting discharge planning activities for psychosocial complex patients, to ensure a timely discharge and to provide appropriate linkage with post discharge care providers.

i. New facility placements

ii. New dialysis patients

iii. Hospice

iv. Sexual assault and concern for human trafficking

v. Homeless

vi. Intimate Partner Violence and assault

vii. Concern for adult, child, animal abuse and neglect

viii. Supportive counsel and intervention

ix. Guardianship

x. Financial/indigent concerns

xi. Other tasks and referrals to community resources, as appropriate

b. Attends to situations exhibiting complex caregiver dynamics that directly impact patient care and discharge.

c. Communicates with interdisciplinary team regarding the discharge planning status of all referred patients.

d. Provides consultation to RN Acute Care Navigators when coordination with intensive community resources is necessary to achieve desired treatment outcomes.

e. Screens, coordinates, and documents post-acute placement and service referrals.

f. Educates patient/caregiver and physician regarding post-acute options and addresses issues of choice.

g. Remains abreast of capabilities and limitations of facilities and resources. Ensures that selected post-hospital services are consistent with the patient’s needs, goals for care, and treatment preferences, and that selected agencies have the capability to provide the care needed.

h. Communicates necessary medical information to appropriate facilities, agencies or outpatient services for follow-up or ancillary care, including all essential information.

i. Facilitates arranging and/or participates in patient/caregiver conferences regarding acute plan of care and/or discharge.

j. Ensures discharge and post-acute management plan consistency across care settings.

k. Actively communicates with all appropriate post-acute care providers throughout patient stay.

5. Serves as a patient advocate during the patient’s hospitalization with a goal of promoting a sense of the continuum of care and a climate of concern for individual patient/caregiver welfare.

6. Provides supportive interventions and resource management related to adult, child, and intimate partner neglect, sexual assault, and violence. Facilitates resources related to socially complex patients such as guardianships, substance abuse treatment, mental health resources, advanced directives, and any other individualized identified resource need. Per regulatory requirements, makes appropriate mandated reporting referrals to APS/CPS on inpatient medical units.

7. Ensures safe care to patients adhering to policies, procedures, and standards, within budgetary specifications, including time management, supply management, productivity, and accuracy of practice.

8. Actively participates in Daily Transition Rounds (DTRs) and contributes to discussion of discharge needs.

9. Identifies transitional care barriers and collaborates in comprehensive, patient-centered care plan development. Reassesses patients and revises the plan as applicable.

10. Follows facility specific acceleration channels to address discharge delays/delays in care.

11. Escalates care progression and coordination concerns per acceleration channels, as appropriate.

12. Communicates with interdisciplinary team and patients/caregivers regarding payor requirements and/or barriers (i.e., payor out of network, denied authorizations, criteria for level of care).

13. Initiates referrals to facility and community indigent programs, as appropriate.

14. Facilitates full team discussion including patient and caregiver(s) when ethical dilemmas arise.

15. Supports other departments, as needed.

16. Responsible for compliance with documentation guidelines as well as regulatory agencies.

17. Facilitates care conferences for complex transitions and/or placement.

18. Maintains positive working relationships with all internal and external customers.

19. Attends applicable conferences, trainings, and meetings. Participates in quality improvement and strategic initiatives.