Discharge Planner/RN (5770)

Responsible for assessing the physical and psychosocial needs of patients and families and provides intervention to meet those needs utilizing personal, family, and community resources. Coordinates with clinical and social service providers across traditional and nontraditional settings including, but not limited to hospitals, primary care offices, homes, social service agencies. Coordinates with health system case managers and leads across boundaries.

Essential Function

Clinician:

Designer/coordinator/integrator/evaluator of care to individuals, families, groups, communities, and identified populations of vulnerable populations.

• Demonstrates ability to understand rationale for care and competently deliver interventions to an increasingly complex and diverse population in multiple environments and settings.
• Performs and/or oversees the holistic assessment and develops a community based plan of care.
• Carries a caseload of complex patients.

Outcomes Manager:

• Synthesizes data and translates into information and knowledge to evaluate and achieve optimal health outcomes.
• Collects data on interventions and outcomes

Advocacy:

• Adept at ensuring that patients, families, and communities are well-informed and included in planning care and is an informed leader for improving care.
• Serves as an advocate for the patient and the professional and interdisciplinary team.

Educator:

• Utilizes appropriate teaching principles and strategies as well as current information, materials and technologies to teach clients, groups and other healthcare professionals.
• Creates, maintains and adjust individualized care plans for patients that address both medical and social barriers to accessing care.
• Works in conjunction with outreach team on intake assessments/care plan including medical needs/barrier identification of patients enrolled in the program; determine plan for care management.
• Promote activities related to the delivery of clinical services, including, but not limited to utilization review, quality assurance and clinical protocol development.

Essential Function

• Plan and execute interdisciplinary case conferences/team meetings and clinical rounds.
• Forge and nurture partnership with hospitals, medical offices and local service organizations to broaden support services for patients.

Implements policies and procedures to ensure that patients are discharged from the hospital with appropriate support systems to prevent re-admission.

Demonstrates the knowledge and skills necessary to provide care appropriate to patient population and within clinical competency. Demonstrates knowledge of the principles of growth and development and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify the requirements of each patient, and to provide the care needed as described in departmental policies and procedures.

Works collaboratively with hospital staff and other community/human services agencies to coordinate intervention activities; ensures that patients receive efficient services for problem resolution.

Utilizes computer and information systems to enter, format data and generates statistics, computations, tables, charts and graphs.

Maintains confidentiality of information in accordance with HIPAA/compliance policies and procedures.

Completes required continuous training and education, including department specific requirements to maintain knowledge of case management and utilization review practices. Responds to problems/opportunities to improve work environment and participates in unit based performance improvement activities.

• Attends in-services, educational programs, conferences and other meetings as required.
• Supports and is involved in the organization’s Performance Improvement initiatives.