PRIMARY FUNCTION:
To assist patients and families to identify social, emotional, and environmental needs and to connect them with available resources/ services through the provision of a full spectrum of discharge planning and social work services.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
Works with the patient, family, and other members of the health care team to formulate a discharge plan that provides the patient services in the appropriate post-acute care setting. Gathers and assesses information regarding the patient's physical needs, mental status, family support system, financial resources, and available community and governmental resources. Employs assessment to develop a comprehensive case management plan that will address the patient s goals of care and identified needs for discharge planning. As part of the discharge plan development process, collaborates with other healthcare professionals in multi-disciplinary meetings and patient rounds. Receives updates and guidance regarding Utilization Management from appropriate UM staff to assist with length of stay coordination.
EDUCATION AND EXPERIENCE REQUIREMENTS: