The Social Worker Discharge Planning reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
The Social Worker is responsible for providing high quality services through the continuum of care to the patient and the patient’s family in order to obtain optimal social and emotional functioning. These services include direct service to patients and their families both on an inpatient and outpatient basis. The Social Worker coordinates options and services to meet the patient’s needs through collaboration and consultation with physicians and other healthcare personnel.
Responsibilities:
- Assure positive patient outcomes through coordinating the discharge planning and social service program identifying patients needing services after discharge with consideration given to normal characteristics of growth and development throughout the life span.
- Works collaboratively with the Medical Staff and other members of the healthcare team to ensure smooth transition and comprehensive discharge plans for their patient and their family.
- Monitors clinical information to support the assessment, treatment, education and continuity among healthcare providers and to enhance and improve individual and organizational performance in patient care.
- Institutes practice changes based upon findings from utilization review and utilization management benchmark data.
- Assures compliance with mandated Medicare/Medicaid initiatives.
- Acts as the hospital and community resource person to help people in the service area find appropriate services.
- Enhances and maintains an environment in which patient safety is a priority as evidenced by:
- Identification of patients at high risk for need of discharge services or assistance
- Use of SBAR and closed loop communication techniques
- Practicing national patient safety goals
- Maintains infection control standards
- Protects client’s rights in accordance with the Illinois Mental Health code and all Healthcare laws.
- Coordinates with patient the activities to meet patient’s goals as evidenced by:
- Working collaboratively as a member of the health care team and with the patient/family/significant other to develop a plan of continuing care compatible with patient needs, goals, and financial resources while giving consideration to the normal characteristics of growth and development throughout the life span. Documenting plan appropriately in Meditech and Midas.
- Family/significant other participation in patient care per patient request/approval.
- Complete all required forms in accordance with the Illinois Mental Health Code.
- Active participation with interdisciplinary team communication and conferencing supporting the formulation, implementation, evaluation, and revision of the plan of care specific to the patient. Documenting care appropriately
- Assists with progression of care with focus in which patient/family/significant other and the interdisciplinary team are aware of and working toward goals to meet the anticipated discharge date.
- Collaborates with interdisciplinary team to address need to move patient to a lower level of care, add/change/delete ancillary service, discharge a patient, change medication/treatment to a less expensive alternative, or provide education when appropriate.
- Identifies potential avoidable days, collaborates with the physician and nursing staff to address potential avoidable days. Documents avoidable days in MIDAS.
- Responds to all insurance reviews and requests in a timely manner.
- Complete insurance pre-certification for psychiatric transfers and DMEs as needed; document necessary insurance information in Meditech and/or MIDAS.
- Understands and supports organizational goals regarding resource utilization as evidenced by
- Functioning as a resource to physicians and hospital staff regarding mental health laws and psychiatric services.
- Supporting and utilizing most effective staffing reflecting census/patient needs
- Identifying cost-saving measures
- Anticipates barriers to patient progress toward goals and performs ongoing assessment to identify patients with discharge needs, or changes in patient discharge needs.
- Complete the transfer of patients to other hospitals with appropriate psychiatric facilities per Physician/Psychiatrist order or at the request of the patient/family. All transfers will be in accordance with EMTALA and Cobra laws and hospital policies.
- Provide referrals based on financial needs and funding.
- Complete insurance pre-certification for psychiatric transfers and DMEs as needed and document necessary insurance information in the patient’s record.
- Provide ongoing patient education including:
- Assessment of learning needs, abilities, preferences, and readiness
- Providing education relating to discharge planning, options, resources, utilization management, advance directives
- Providing for informed patient decision-making regarding above topics
- Serves as a resource for those seeking information about services and care available in the surrounding community area and assists people in finding information/resources for services that are available in distant areas.
- Responds to Code 999, when present in the Hospital
- Assist in the de-escalation of behavioral patients
- Assist in the medical staff to secure the safety of the patients to include restraints as needed.
- Documentation of all interventions within a code 999 to include restraints and debriefing with the medical staff.
- Responds to Code Blue and Rapid Response, when present in the Hospital
- Assist with the communication and supportive services to all present family
- Contact family via phone to communicate any current medical status and provide supportive services.
- Assist the medical staff to coordinate appropriate resources for family to include housing or local services.
- Documentation of all interventions within the code and services provided. Recognizes, responds, provides education and appropriately refers requests for problem intervention to include, but not limited to:
- Recognizes, responds, and appropriately refers requests for problem intervention in accordance to the Illinois Mental Health and Developmental Disabilities Code to include:
- Acts as a resource to patients, community, and interdisciplinary team for mental Health Laws and advanced directives.