Licensed Practical Nurse with experience in medical/surgical, critical care and/or hospice, home health or public health required.
Assesses the health status of patients referred for discharge planning within one business day of consult utilizing in-depth information about a patient's situation from History and Physical and patient assessment to develop a case management plan with goals and interventions. Reviews all tasks daily for follow up of assignment. Coordinates and Prioritizes discharges daily in timely manner. Makes daily patient/family rounds maintaining communication with all members of healthcare team. Promotes a timely, cost-effective, efficient, and safe discharge plan to community services including long-term care, home health services, etc. On a concurrent basis assesses appropriateness of discharge disposition and communicates any changes in plan/needs with appropriate resources. Develops, implements, and manages processes for referrals to Home Health, HME, SNF, and other agencies/facilities. Collaborates with: Medial Staff, admitting office, HIM, patient accounts, and patient care departments to ensure effective and efficient communication of efforts and activities. Assists with development and implementation of clinical paths and variance tracking if applicable. Tracks avoidable days and adverse advents on all patients. Assists staff in clinical decision-making and priority setting to ensure an optimal length of stay. Initiates Guardianship/Adult Protective Service/Child Protective Service referrals when appropriate and communicates with all necessary disciplines and agencies.Utilizes approved departmental communication tools for documentation. (Canopy/Providerlink) Maintains active participation and membership in service lines and assists with patient education classes as requested. Acts as Liaison for interdisciplinary communication and coordination of discharge plan.
Collaborates with nursing staff, Utilization Review Nurses, other Discharge Planning Coordinators, ancillary staff, Hospitalists team and physicians to identify patient/family educational needs. Is accountable for identifying own learning needs and seeking sources of information. Communicates with Physicians, patients/families to ensure understanding of third party payor guidelines. Utilizes critical thinking and problem solving techniques.
Is able to work independently, exercising sound judgment, discretion, and initiative to facilitate change.