Social Worker - Discharge Planning Coordinator - Toledo Hospital - Care Navigation - Part Time - Days

POSITION SUMMARY

The Social Worker/Discharge Planning Coordinator intervenes with patients who arepsychosocially complex have Social Determinants of Health (SDOH) needs and/or requireassistance with transitions of care or discharge planning. In addition the Social Worker/DischargePlanning Coordinator offers supportive intervention (i.e. trauma terminal diagnosis mentalhealth etc.) to patients and caregiver(s) and coordinates and facilitates the development of adischarge plan of care for high-risk/complex patient populations. They may self-refer or receivereferrals for patients from interdisciplinary team members and are responsible for collaboratingwith the care team (Physicians Nurses RN Acute Care Navigators Care Navigation CoordinatorsContracted Vendors etc.) and escalating appropriately to ensure their assigned patients receivesexceptional 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 patients and caregivers psychosocial risk factors through evaluation ofprior functioning levels appropriateness and adequacy of support systems reactionto illness and ability to cope.

b. Intervenes with patients and caregivers regarding emotional social and financialconsequences of illness and/or disability; accesses and providescaregiver(s)/community resources to meet identified needs.

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

d. Advocates for patient and caregiver empowerment and independence to makeautonomous health care decisions and access needed services within the healthcaresystem.

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

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

2. Identifies patients most at risk for readmission without intensive discharge planning throughinformation gathered on the admission nursing database EMR predictive analytics tools andproactive case finding.

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

4. Complex Discharge Planning:

a. Participates in supporting discharge planning activities for psychosocial complexpatients 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 impactpatient care and discharge.

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

d. Provides consultation to RN Acute Care Navigators when coordination with intensivecommunity 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 addressesissues of choice.

g. Remains abreast of capabilities and limitations of facilities and resources. Ensuresthat selected post-hospital services are consistent with the patients needs goals forcare and treatment preferences and that selected agencies have the capability toprovide the care needed.

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

i. Facilitates arranging and/or participates in patient/caregiver conferences regardingacute 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 throughoutpatient stay.

5. Serves as a patient advocate during the patients hospitalization with a goal of promoting asense of the continuum of care and a climate of concern for individual patient/caregiverwelfare.

6. Provides supportive interventions and resource management related to adult child andintimate partner neglect sexual assault and violence. Facilitates resources related to sociallycomplex patients such as guardianships substance abuse treatment mental healthresources advanced directives and any other individualized identified resource need. Perregulatory requirements makes appropriate mandated reporting referrals to APS/CPS oninpatient medical units.

7. Ensures safe care to patients adhering to policies procedures and standards withinbudgetary specifications including time management supply management productivity andaccuracy of practice.

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

9. Identifies transitional care barriers and collaborates in comprehensive patient-centered careplan 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 asappropriate.

12. Communicates with interdisciplinary team and patients/caregivers regarding payorrequirements and/or barriers (i.e. payor out of network denied authorizations criteria forlevel 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 dilemmasarise.

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 improvementand strategic initiatives.

REQUIRED QUALIFICATIONS

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 beable 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. Excellentinterpersonal communication and negotiation skills. Critical thinking and problem-solving skills.Customer service skills. Ability to work and communicate with people of all social economic andcultural backgrounds; be flexible open-minded and adaptable to change. Effective organizationalskills. Computer proficiency with Outlook e-mail and electronic medical records. Flexible in acomplex and changing healthcare environment. Understanding of pre-acute and post-acutevenues of care and post-acute community resources. Maintains a current working knowledge ofservices available in the local community particularly services available to patients with limited ornon-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 hospitaland 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 rapidlyfor long periods of time.

ProMedica is a mission-based not-for-profit integrated healthcare organization headquartered in Toledo Ohio. For more information please visit applicants will receive consideration for employmentwithout regard to race color national origin ancestry religionsex/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

Equal Opportunity Employer/Drug-Free Workplace