Discharge Planner - Transition of Care

Licensed Social Worker or LPN

This position provides Discharge Planning Services for all Inpatient Admissions. The process of completing the Discharge Plan begins at the time of admission into the hospital and continues through the day of discharge. The Discharge Plan will include input/orders from the Attending Physician, establishing and maintaining communication pathways between the Hospital, Post-Acute Providers and the patient/family, problem solving around difficult Disease Management issues, and identifying and communicating Performance Improvement opportunities across the Continuum of Care.

LPN - Develop and complete a Discharge Plan to include completion of various risk and care assessment documents
Document in the Electronic Medical Record all relevant Discharge Planning work
Make Referrals to appropriate Post-Acute Service based on the completed Discharge Plan
Complete daily tracking on all assigned patients (Excel spreadsheet, or other electronic tracking tool)
Participate in Data Analysis and Performance Improvement activities, meeting, etc.
Provide effective Hand-Off to Transition of Care Navigation Services for High Risk Populations that receive Post-Acute Navigation Services.

Social Worker - Develop and complete a Discharge Plan to include completion of various risk and care assessment documents
Complete daily tracking on all assigned patients (Excel spreadsheet, or other electronic tracking tool)
Provide input and help to strategize and problem solve in the instances of difficult social situations or DHR involvement as needed across the Transition of Care team.
Liaison between the Hospital and Post-Acute Providers for HIGH RISK Populations
Organize and Facilitate weekly Post-Acute Huddle calls
Document in the Electronic Medical Record all correspondence with Post-Acute Providers
Complete daily tracking on all assigned patients (Excel spreadsheet)
Participate in Data Analysis and Performance Improvement sessions

• Valid Alabama or MSL LPN preferred; BLS certification provided.
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• LBSW required; Two (2) years’ experience in a healthcare setting. Experience in the Acute Care or Post-Acute Care Setting is preferred.