Social Worker / Discharge Planning Coordinator - Care Navigation - Per Diem - Days - ProMedica Toledo Hospital (TH)
Sylvania, OH
About the Job
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.
Education: BSW or higher degree; will consider a limited license SW on individual basis.
Skills: Must have knowledge of regulations, requirements, and community resources. Must be able to function effectively in a critical care environment. Written and verbal skills are essential. Must be able to establish priorities and communicate and respond to inquiries. Excellent interpersonal communication and negotiation skills. Critical thinking and problem-solving skills. Customer service skills. Ability to work and communicate with people of all social, economic, and cultural backgrounds; be flexible, open-minded, and adaptable to change. Effective organizational skills. Computer proficiency with Outlook e-mail and electronic medical records. Flexible in a complex and changing healthcare environment. Understanding of pre-acute and post-acute venues of care and post-acute community resources. Maintains a current working knowledge of services available in the local community, particularly services available to patients with limited or non-existent payment resources.
Years of Experience: N/A
License: Licensed Social Worker
Certification: N/A
PREFERRED QUALIFICATIONS
Education: MSW
Skills: Applicable experience in patient advocacy, care management, and knowledge of hospital and community resources.
Years of Experience: Previous case management or discharge planning experience.
License: N/A
Certification: Specialty certification in care management (CCM, ACM, or similar).
WORKING CONDITIONS
Personal Protective Equipment: N/A
Physical Demands: Must be able to stand for long periods of time. Must be able to work rapidly for long periods of time.
ProMedica is a mission-based, not-for-profit integrated healthcare organization headquartered in Toledo, Ohio. For more information, please visit www.promedica.org/about-promedica
Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category . In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact employment@promedica.org
Equal Opportunity Employer/Drug-Free Workplace