Responsible for moving patients from admission through discharge without disruption to their care through the process of assessment, planning, implementation, coordination, monitoring evaluation and outcome assessment of assigned patient caseload.Ensures delivery of the appropriate level of care based on patient needs and hospital capabilities.Serves as a clinical resource to patients, families and staff in the coordination of care to all patients.Works collaboratively with the interdisciplinary team to provide a continuum of comprehensive cost-effective care.Monitors outcomes as a process of continuous improvement.
This job description is intended to cover the minimum essential duties assigned on a regular basis. Associates may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.
<<<Core Components of Discharge Planning>>>
Discharge Planning Concepts - establishing quality measures and boundaries of practice in accordance with case management process, tools, standards, models, goals objectives and performance improvement concepts.
Discharge Planning Principles and Strategies- maintaining standards of professional practice of confidentiality, conflict resolution strategies, negotiation skills, ethics and advocacy.
Psychological and Support Systems - implements and integrates culturally sensitive strategies including clients needs surrounding spiritually, wellness and illness management, behavioral and psychiatric care, psychosocial aspects of illness complementary medicine family dynamics as well as working knowledge of caring for victims of abuse.
Healthcare Management and Delivery - ensures care management occurs for assigned caseload across the continuum of Care. Develops collaborative relationships with providers.
Healthcare Reimbursement - participates in Revenue cycle management by incorporating discharge planning principles by cost containment principles, healthcare insurance principles and cost containment practices.
Vocational Concepts and Strategies - address the needs of assigned patient caseload as the patient moves along the healthcare continuum towards the lowest level of care including disability compensation, vocational and financial aspects of chronic illness and disability and work adjustments.
As a part of service delivery, performs an initial comprehensive assessment of the patient including review of the medical record to determine discharge needs and utilization management.
Facilitating timely discharges to the appropriate level of care.
Concurrent Clinical Management - Care Coordination
Coordinates care within the framework of the multi-disciplinary plan of care to facilitate patient's progress along the healthcare continuum outcomes, which includes discharge. Acts as a clinical resource for the multi-disciplinary team. Monitors resource utilization in according to the plan of care, clinical pathway and patient diagnosis.
This is accomplished by:
Assertive care coordination among the interdisciplinary team
Coordinating care using Pathways or Plan of Care and participating in the ongoing development and revision of Pathways and Plan of Care.
Identifying and preventing common patient complications and works to prevent.
Performs and documents all aspects of Transitional Planning including:
Assessment - collects and analyzes in-depth information of the patient’s current health status and needs from all relevant sources
Planning - plans a client centered, need based transitional plan that is realistic, patient oriented and time specific.
Implementation - enacts transitional plan that effectively moves the patient along the care continuum. Effectively works with the community to identify and allocate post discharge needs.
Coordination - aggregates and secures all resources to effectively accomplish the goals set forth in the initial Discharge Planning assessment
Monitoring - utilizes all relevant resources to gather sufficient information regarding the effectiveness of the plan
Evaluation - seeks feedback from all relevant sources regarding the effectiveness of the Discharge Plan.
Outcomes - evaluates outcomes related to the Case coordination process including LOS, Readmission reports, patient satisfaction and financial variances related to case coordination participation in the patients care. Reports pertinent variances.
*Licensed as a Social Worker in the state of Michigan *BCLS *Demonstrates excellent case management knowledge through certification. If not already certified when assuming this position, national case management certification will be required within three years as condition of continued employment in this position
* Minimum three years of Social Work experience in an acute care setting *Preferred- Experience in acute care utilization review,discharge planning
*Master's of Social Work degree from an accredited School of Social Work
Specialized Knowledge and Skills
*Demonstrates ability to handle multiple tasks concurrently. *Demonstrates ability to quickly adapt to change and work with ambiguous parameters. *Demonstrates ability to work independently, organize and prioritize work to meet all deadlines. *Demonstrates excellent verbal and written communication *Demonstrate ability to work in stressful situations, manage conflict and assume a leadership role. *Maintains an atmosphere that supports and encourages high performance, high levels of Caregiver engagement, teamwork, customer service, and continual improvement within a specific area of responsibility. *Ability to work with a team *Strongly supports the direction of Sparrow and the members of the Sparrow team *Ability to utilize word processing, spreadsheet, presentation programs and other software relevant to the job
Sparrow Health System is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veteran status.