Discharge Planner/RN (5001)

Coordinates the discharge planning functions within acute hospital setting. This includes needs assessment, assistance in financial resource management, crisis management, service delivery planning and referrals to external agencies/community-based services and programs.

Essential Function

Demonstrates knowledge and skills necessary to perform assessment and implement discharge planning services, maintains clinical competency and meets age-specific patient needs in accordance with established protocols, policies and procedures.

• Assessment
  • Collects key information from patient, family, community agencies, and other professional disciplines as part of medical social work assessment.
  • Determines priorities for intervention with special consideration given to discharge planning and the patient's right of self-determination.
  • Determines differential treatment needs of patients and families.
  • Provides specialized methods of services based upon assessment of needs.
  • Documents assessment, including recommendations and professional judgment.
• Discharge Planning
  • Provides information to patient and families about types and costs of services available to enable them to make informed decisions.
  • Completes assessments and plans documenting patient and family's understanding of and input into development of the plan.
  • Communicates to appropriate staff information about the patient's discharge plan and schedule multi-disciplinary team conferences for patients/families with complex needs or where complex arrangements are required.
  • Collaborates with the multidisciplinary care team to identify patients at risk for readmissions and implements plans of care to reduce risk.
  • Initiates referrals to agencies and make a direct referral to enhance service to the patient/family.
  • Assists patients in obtaining appropriate services to meet needs such as DME, outpatient therapy, hearing/optical appliances, nursing home, home care and dialysis. Obtains and/or completes required documentation.
  • Serves as a resource to multi-disciplinary team in providing information and education about community resources.
  • Helps coordinate arrangements for patients with special transportation needs transferring from the hospital.
  • Obtains and/or completes required documentation.
  • Documents discharge plan in medical record.
  • Maintains an effective relationship with collateral agencies and includes them in multi-disciplinary team conferences when this will improve patient care.

Functions as a member of a multi-disciplinary healthcare team. Participates in the patient satisfaction survey.