Collaborates with the bedside nurse and clinical team, meets with patient and or family to complete an initial discharge planning assessment within 24 hours of patient admission. Identifies patients and families with complex psychosocial, financial and legal discharge planning needs requiring a Social Work referral. Develops, documents and implements a discharge plan consistent with individual patient needs and with patient and family goals. Develops plans with attention to individual patient and family goals. Discusses estimated length of stay, treatment plan and discharge plan with attending physician and or medical team. Ensures that the Interdisciplinary Care Plan and Discharge Plan are consistent with patient clinical course, continued care needs and covered services. Refers to appropriate alternate site agency based on post discharge needs and patient choice. Provides linkage to community resources and UH network services to facilitate optimal care, and serves as liaison to community agencies. Communicates and collaborates with the work team using a multidisciplinary approach. Provides guidance and consultation to peers and team regarding complex psychosocial and or discharge planning issues or barriers. Participates in Interdisciplinary Team rounding. Coordinates discharge teaching. Collaborates with bedside nurse and members of Interdisciplinary Team to support teaching efforts, with special attention to situations where patient and family education requiring teach back and show back are required. Collaborates with Case Management or Utilization Review to clarify patient status, plan of care, barriers to discharge and discharge readiness.Ensures timely completion of discharge, transfer and or referral forms and discharge order. Coordinates activities to ensure patient appeal rights under Notification of Hospital Discharge Appeal Rights.
Collaborates with the bedside nurse and clinical team, meets with patient and or family to complete an initial discharge planning assessment within 24 hours of patient admission. Identifies patients and families with complex psychosocial, financial and legal discharge planning needs requiring a Social Work referral. Develops, documents and implements a discharge plan consistent with individual patient needs and with patient and family goals. Develops plans with attention to individual patient and family goals. Discusses estimated length of stay, treatment plan and discharge plan with attending physician and or medical team. Ensures that the Interdisciplinary Care Plan and Discharge Plan are consistent with patient clinical course, continued care needs and covered services. Refers to appropriate alternate site agency based on post discharge needs and patient choice. Provides linkage to community resources and UH network services to facilitate optimal care, and serves as liaison to community agencies. Communicates and collaborates with the work team using a multidisciplinary approach. Provides guidance and consultation to peers and team regarding complex psychosocial and or discharge planning issues or barriers. Participates in Interdisciplinary Team rounding. Coordinates discharge teaching. Collaborates with bedside nurse and members of Interdisciplinary Team to support teaching efforts, with special attention to situations where patient and family education requiring teach back and show back are required. Collaborates with Case Management or Utilization Review to clarify patient status, plan of care, barriers to discharge and discharge readiness.Ensures timely completion of discharge, transfer and or referral forms and discharge order. Coordinates activities to ensure patient appeal rights under Notification of Hospital Discharge Appeal Rights.
3-5 years of experience RN - Registered Nurse 2 years experience in case management or discharge planning in an acute care setting, Bachelors degree preferred, CM certificate preferred.