Coordinates and optimizes throughput activities to optimize high risk patient outcomes including:

• Completes thorough chart review upon referral and throughout patient’s stay.
• Attends Bed Huddles and Care Conferences daily to promote throughput activities.
• Provides information to Care Coordinator and Charge Nurse related to pending and confirmed discharges to leadership and the Logistic Center to assist in Throughput throughout patient’s hospitalization.
• Participates in ongoing communication with physician and interdisciplinary team to develop a collaborative relationship aimed at improving clinical treatment goals and appropriate and timely discharge for the patient.
• Proactively educates patients upon referral about advance directives, options for post-acute services and community resources available to them at discharge.
• Completes proactive initial and ongoing psychosocial assessments that holistically assess the patient for potential complex post- acute needs. (i.e. assesses for abuse/neglect/substance abuse/mental health/homeless/end of life/ lack of payor/ facility placement issues.)
• Provides support to patients with issues related to adjustment to illness and assists in securing support for them post hospitalization.
• Identifies hospital and community based resources which will meet patient/family needs and provides referrals and advocacy in obtaining services.
• Maintains active interaction with the patient/family throughout the treatment/discharge planning process in efforts to keep them apprised of discharge planning activities.
• Proactively makes appropriate referrals to internal and post-acute service providers to ensure continuity of care during and post hospitalization.
• Provide expertise to the team in developing treatment and discharge planning strategies for frequently admitted patients.
• Assists in the procurement of services and serves as an advocate on behalf of patient/family for scarce resources.
• Maintains high team standards by addressing coordination problems within the functioning of the healthcare team.
• Identifies and escalates any issues that relate to LOS/Throughput/Readmission management.
• Provides to patients, families, and hospital staff education regarding post- acute services (LTACH, acute rehabilitation, nursing facility, hospice, etc.) Opportunities for conducting education may include patient families at bedside, one-on-one staff education, and unit department meetings.

Maintains skills and knowledge as appropriate to the medical social work role. Participates in continuing education to fulfill licensure requirements.

Documents throughput/ discharge planning activities according to departmental policies.

• Completes data collection via designated software for all patients.
• Identifies and documents all social work intervention and discharge planning activities in appropriate software.
• Communicates only appropriate necessary information on chart applicable to the referral source in accordance with HIPPA guidelines

Performs other duties as assigned.

MINIMUM

Education, Credentials, Licenses:

Graduate of an accredited Baccalaureate school of social work. Licensed as a SW to practice social work in the state where work is being performed. Meets contact hour requirements for licensure, including all state required courses.

Specialized Knowledge:

Knowledge of psychosocial issues re: health related problems and post-acute care needs.

Excellent communication skills and the ability to coordinate care well with an interdisciplinary team.

Kind and Length of Experience:

None required.