To provide professional discharge planning services through assessments, and coordination of post-hospital care needs to patients and their families. Provides resources and choices to families to effectively link them to the needed level of emotional, medical and spiritual care. This role will receive referrals for individuals from at-risk populations from interdisciplinary team members (including physicians, Care Managers, staff nurses and other members of the care team). Participates as an active member of multi-disciplinary team.
Complex Discharge Planning based on assessment of patient and family needs, preferences and available resources in order to ensure a timely discharge and to provide appropriate linkage with post-discharge care providers( i.e. New/Resumptions SNF, LTAC, Rehab, Dialysis, Hospice, DME and Home Health etc.)
.Develops discharge plan in direct consultation with patient, family, physician, and healthcare team. Deals with families exhibiting complex family dynamics that directly affects patient care and discharge.
Manages complex cases/situations and intervenes with and advocates for patients and families as plan of care and discharge plan are developed. Educates patients and families regarding appropriate resources, access to services and third party requirements, and makes appropriate and timely referrals to address post-acute discharge needs.
Provides consultation to Case Managers when coordination with significant or intensive community resources is necessary to achieve desired treatment outcomes.
Uses knowledge of insurance benefits and coverage guidelines to maximize appropriate utilization of resources.
Maintains effective communication and working relationships with members of the interdisciplinary team.
Attends care conferences/unit huddles or other care planning meetings as per department policy.
Partners with external agencies and facilities to provide continuity of care for patients and families.
Documents all interventions and discharge plans to provide the health care team with accurate and up-to-date information regarding development/progress of the discharge plan and psychosocial interventions with responses.
Shift: Requesting minimum 4 shifts per month, 2 holidays per year.
Requirements:
Required: Master's Degree
Specify Degree: masters in Social Work
Minimum Experience:
2-3 years of previous job related experience
Licensure/Certifications
Required: Licensed Social Worker State of Illinois
Preferred: License Clinical Social Worker State of Illinois
Trinity Health's Commitment to Diversity and Inclusion
Trinity Health employs about 133,000 colleagues at dozens of hospitals and hundreds of health centers in 22 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.