About This Role
This role involves holistically assessing patients and families for discharge planning needs within inpatient, observation, and emergency departments. It focuses on developing and executing timely care coordination plans, leveraging technology for communication with post-acute services, and actively participating in multidisciplinary rounds to ensure seamless transitions for patients.
Responsibilities
- Provide grief counseling, disease adjustment support, crisis intervention, goals of care planning support, and de-escalation services for patients as appropriate
- Assess patients' and families' holistically for discharge planning needs in the inpatient, observation, and/or emergency departments, including prior functioning, support systems, financial, and psychosocial in a timely fashion to avoid delays in discharge planning
- Review the medical record, including medications, history and physical, labs, and progress notes and incorporate the clinical, social, and financial factors into the transition of care plan
- Develop discharge plans with appropriate contingency plans throughout the hospital stay to ensure timely care coordination and progression of care, making arrangements for post-acute care services and facilities as well as community care for social needs
- Leverage technology and follow standard work and best practices to communicate with post-acute care services and facilities to ensure patient care information is communicated for continuity of care, medical records are complete, and discharge reconciliation is accurate
- Actively participate in multi-disciplinary rounds to review changes in patient status, progression and level of care, and discharge plans for all assigned patients to identify resources necessary at discharge and ensure a timely transition, escalating care delays to leadership as appropriate
- Communicate with and educate patients and families regarding emotional, social, and financial impacts of illness and mobilize family/community resources to meet identified needs while advocating for patient and family empowerment in making health care decisions and accessing needed services
- Organize and facilitate patient and family care conferences with the multidisciplinary team
- Document discharge planning evaluation, ongoing assessment, discharge plans, MDRs, barriers to progression of care, avoidable days, and patient and family needs according to standard work
- Provide patient and family advocacy, and support patient's choice and patient rights during hospitalization
- Communicate with Payors patient's needs for authorization for post-acute care as needed
- Assess readmitted patients for the patient's and family's perceived reasons for the readmission
- Other duties as assigned
Requirements
- Excellent interpersonal communication and negotiation skills
