Discharge Planner - Skilled Nursing Facility

Overview

A nursing home discharge planner is a healthcare professional responsible for coordinating and managing the transition of residents leaving a nursing home by assessing their needs, developing personalized discharge plans, arranging necessary post-discharge services, educating residents and families, and advocating for their needs to ensure a smooth transition to their next care setting, whether it be home, assisted living, or another healthcare facility ; they work closely with medical staff, social workers, and other healthcare providers to facilitate optimal patient care throughout the discharge process.

Key responsibilities of a nursing home discharge planner may include:

• Patient assessment:
  
  

Conducting comprehensive assessments of residents' medical, functional, social, and psychological needs to identify discharge requirements.

• Discharge plan development:
  
  

Creating individualized discharge plans that address the resident's specific needs, including necessary follow-up care, medication management, and community resource referrals.

• Collaboration with healthcare team:
  
  

Working closely with nursing staff, physicians, social workers, therapists, and other healthcare providers to ensure coordinated care and timely discharge planning.

• Family education:
  
  

Providing detailed information to residents and their families regarding discharge plans, post-discharge care instructions, and available community resources.

• Care coordination:
  
  

Arranging necessary home healthcare services, transportation, equipment, and other support systems to facilitate a safe discharge.

• Advocacy:
  
  

Representing the resident's needs and advocating for appropriate placement and services to ensure their well-being after discharge.

• Insurance and financial navigation:
  
  

Working with insurance companies and managing financial aspects related to discharge planning, including eligibility verification and billing procedures.

• Documentation:
  
  

Maintaining accurate and detailed documentation of discharge plans, resident progress, communication with healthcare providers, and family interactions.

Required Skills And Qualifications

• Clinical knowledge:
  
  

A strong understanding of geriatric nursing practices, medical conditions, and common functional limitations of elderly patients.

• Communication skills:
  
  

Excellent verbal and written communication skills to effectively interact with residents, families, and healthcare team members.

• Interpersonal skills:
  
  

Ability to build rapport, actively listen, and address concerns with empathy and compassion.

• Organizational skills:
  
  

Strong organizational skills to manage complex caseloads, prioritize tasks, and meet deadlines.

• Problem-solving skills:
  
  

Ability to assess situations, identify potential barriers, and develop creative solutions to address complex discharge needs.

Educational background: LPN or Licensed Social Worker