Corewell Health
Discharge Planner
Responsible for, and will participate in, the assessment, planning, implementing, coordinating, communicating and finalizing the discharge of the patient/resident from the hospital setting or rehab and nursing center. Works with other members of the health care team both inpatient and outpatient, to advocate for and ensure appropriate aftercare and follow up. Essential Functions
Competently gathers information using assessment skills to identify physical, psychosocial, financial and environmental health care needs of the patient/resident. Assess and identify appropriate resource utilization, level of care and treatment options to develop a plan of care that will impact quality outcomes in a cost effective manner. Collaborates with the patient/resident, family and health care team to promote quality care, prevent delay in discharge and complications to improve outcomes. Work with the patient and physician to develop a plan of care that meets their needs and will avoid duplication and or fragmentation of services. Ensure appropriate use of ancillary services providing guidance and direction and implementing modification to the plan of care as needed. Efficiently documents assessments, clinical findings, completed tasks, plan for treatment and progress toward goals for discharge. Keep accurate record of patient/family contact and team consultation. Works to actively facilitate an appropriate level of care for discharge and educate the patient on the progress of the discharge plan and the safety and benefits of the plan. Monitor, evaluate, and coordinate referrals from multiple sources, while measuring patient care outcomes, interpreting reports and addressing data from sources to better serve and impact the patient and their adjustment to illness and treatment. Actively promotes frequent communication between all team members, providers, patients and family members to ensure a smooth transition from one level of care to another. Share and educate on community resources, support systems and available benefits. Maintain communication with providers delivering care to ensure consistency in communication to patient/resident and family. Demonstrate self directed, self motivated, responsible behavior recognizing when there is a need for adjustment and flexibility in professional function. Respect confidentiality of all parties involved in the patient/resident care process and utilize the professional skills of other team members and disciplines for improvement in the discharge plan. Required: Bachelor's Degree Social Work: Exceptions for persons without a social work degree can be made for those who have a human services degree and carry a current social work license OR Bachelor's Degree Social Work or a human services field including, but not limited to, Sociology, Gerontology, Special Education, Rehabilitation Counseling, and Psychology (Rehab and Nursing Centers only) 1 year of relevant experience Supervised social work experience in health care setting working directly with individuals. (Rehab and Nursing Centers only) LIC-Bachelor Social Worker (BSW) - State of Michigan Excludes Rehab and Nursing Centers Upon Hire required Preferred: 1 year of relevant experience skilled nursing home process and procedure 1 year of relevant experience mental health, substance abuse assessment and treatment 1 year of relevant experience community resources and discharge planning 3 years of relevant experience Hospital or Nursing Home Social work
Responsible for, and will participate in, the assessment, planning, implementing, coordinating, communicating and finalizing the discharge of the patient/resident from the hospital setting or rehab and nursing center. Works with other members of the health care team both inpatient and outpatient, to advocate for and ensure appropriate aftercare and follow up. Essential Functions
Competently gathers information using assessment skills to identify physical, psychosocial, financial and environmental health care needs of the patient/resident. Assess and identify appropriate resource utilization, level of care and treatment options to develop a plan of care that will impact quality outcomes in a cost effective manner. Collaborates with the patient/resident, family and health care team to promote quality care, prevent delay in discharge and complications to improve outcomes. Work with the patient and physician to develop a plan of care that meets their needs and will avoid duplication and or fragmentation of services. Ensure appropriate use of ancillary services providing guidance and direction and implementing modification to the plan of care as needed. Efficiently documents assessments, clinical findings, completed tasks, plan for treatment and progress toward goals for discharge. Keep accurate record of patient/family contact and team consultation. Works to actively facilitate an appropriate level of care for discharge and educate the patient on the progress of the discharge plan and the safety and benefits of the plan. Monitor, evaluate, and coordinate referrals from multiple sources, while measuring patient care outcomes, interpreting reports and addressing data from sources to better serve and impact the patient and their adjustment to illness and treatment. Actively promotes frequent communication between all team members, providers, patients and family members to ensure a smooth transition from one level of care to another. Share and educate on community resources, support systems and available benefits. Maintain communication with providers delivering care to ensure consistency in communication to patient/resident and family. Demonstrate self directed, self motivated, responsible behavior recognizing when there is a need for adjustment and flexibility in professional function. Respect confidentiality of all parties involved in the patient/resident care process and utilize the professional skills of other team members and disciplines for improvement in the discharge plan. Required: Bachelor's Degree Social Work: Exceptions for persons without a social work degree can be made for those who have a human services degree and carry a current social work license OR Bachelor's Degree Social Work or a human services field including, but not limited to, Sociology, Gerontology, Special Education, Rehabilitation Counseling, and Psychology (Rehab and Nursing Centers only) 1 year of relevant experience Supervised social work experience in health care setting working directly with individuals. (Rehab and Nursing Centers only) LIC-Bachelor Social Worker (BSW) - State of Michigan Excludes Rehab and Nursing Centers Upon Hire required Preferred: 1 year of relevant experience skilled nursing home process and procedure 1 year of relevant experience mental health, substance abuse assessment and treatment 1 year of relevant experience community resources and discharge planning 3 years of relevant experience Hospital or Nursing Home Social work