Performs high level triage of all patients, with focus on identifying those with complex psych-social or financial issues, placement needs and community service needs within 24 hours of admission.
Receives RN Care Manager referrals to social work based on identified Social Work Triggers (see SW Referral Standard Operating Procedure - SOP).
Identifies and assesses barriers early in the patient's stay, formulating a plan with the patient, family, internal and external members of the healthcare team, payers, and community resources. (e.g., LOS barriers to D/C)
Assesses patient and family needs for support and community service needs (Meals on Wheels, Sitters, etc.); educates and refers them to community resources, access to services, arrange for appointments and establishes rapport with other agencies.
Assesses risk of readmission for specified patient populations and initiates assigned interventions that will enhance the patient's ability to successfully transition along the care continuum.
Identifies the need for, arranges, and participates in family care conferences; participates in interdisciplinary conferences and provides consultation for patient, families, and clinical staff (e.g., attends care conferences/unit rounds/huddles).
Identifies and reports avoidable day/variances and/or service delays from established plan of care to leadership.
Identifies patient and family preferences, needs and strengths, to foster for the interdisciplinary team in compliance with standards of care.
Interviews patient and significant others to assess patient's psychosocial situation and identifies which family member is the point of contact.
Develops discharge plan in direct consultation with patient, family, physician, and health care team.
Manages complex cases/situations and intervenes with and advocates for patients and families as plan of care and discharge plan are developed. Complex discharge planning identified from SW triggers (see SW Referral Standard Operating Procedure - SOP)
Uses knowledge of insurance benefits and coverage guidelines to maximize appropriate utilization of resources.
Documents in the EMR: assessment, plans, interventions, barriers, and reassessments as necessary to facilitate discharge and/or transitions; ensures all pertinent information is transferred to post-acute agency.
Works collaboratively with the RN Care Manager, other disciplines, and internal and external members of the healthcare team to ensure a safe, appropriate, and timely transition to the next level of care, taking into consideration the patient's available resources.
Partners with external agencies and facilities to provide continuity of care for patient and family empowerment and independence to make autonomous health decisions.
Represents the integrated care management department on various teams and performance outcomes committees and projects.
Performs other related duties as required and directed.
...Style Advisors, Sports Club LA Equinox Group is a high growth collective of the world's most influential, experiential, and differentiated... ...we practice what we preach investing time in our own health and fitness. We believe that everyone has untapped potential within them and...
...to make your mark with the worlds largest equipment rental provider, come build your future with United Rentals! As a Class A CDL Driver (Class 1) at United Rentals, your goal will be to deliver equipment to our customers in a safe, timely, efficient and courteous...
International High School AP Psychology Teacher Job Description: 1. Location: Beijing city, China. 2. Contract Term: one academic year, ASAP - July 2027. 3. Students Age: 15-18 years old. 4. Work Days: work on Mondays to Fridays, two days off on weekend. 5. Work...
...rewards, recognition, and respect Position Purpose: This van driver role is responsible for driving a van intrastate and/or... ...food related products to customers. This role generally handles deliveries of urgent orders. All routes are expected to be completed safely...
...Job Description Job Description Tank Farm Operators are responsible to acquire information and training needed to enable them to carry... ...record accurate weights of tank trucks, ISO containers, and rail cars. Transfer refrigerant to and from storage tanks. Sample...