Discharge Planner

Description

Job Summary

The Discharge Planner is a vital member of the healthcare team responsible for coordinating and facilitating the smooth transition of residents from our Skilled Nursing Facility (SNF). This position requires an organized and compassionate individual with a focus on ensuring that the discharge process is well-planned, individualized, and supportive of the resident's continued care needs.

Key Responsibilities

1. Assessment and Planning:
   • Conduct comprehensive assessments of residents' care needs, discharge goals, and post-discharge support requirements.
   • Collaborate with the interdisciplinary healthcare team to develop individualized discharge plans.
2. Communication:
   • Communicate regularly with residents, their families, and healthcare providers to discuss the discharge process, expectations, and post-discharge care plans.
   • Serve as a liaison between our SNF, home healthcare agencies, rehabilitation centers, and other post-acute care providers.
3. Resource Coordination:
   • Coordinate services and resources required for post-discharge care, including home health services, medical equipment, and follow-up appointments.
   • Collaborate with external providers to ensure a seamless transition of care.
4. Documentation:
   • Maintain accurate and up-to-date documentation of discharge plans, goals, and communication with residents and families.
   • Ensure compliance with regulatory standards and facility policies.
5. Patient Advocacy:
   • Advocate for residents' needs and preferences in the development of discharge plans.
   • Assist residents and families in understanding and navigating the post-discharge care process.
6. Education and Support:
   • Provide education to residents and their families on the management of chronic conditions, medications, and self-care strategies post-discharge.
   • Offer emotional support and counseling as needed during the discharge planning process.
7. Follow-up:
   • Conduct follow-up assessments and communication after discharge to assess the success of the transition and address any issues that may arise.
   • Collaborate with our SNF healthcare team to evaluate and improve the discharge planning process.

Qualifications

Preferred Qualifications and Skills

• Bachelor's degree in Social Work (MSW, BSW, LCSW), Nursing (LPN/RN), or a related field.
• Experience in discharge planning, preferably in a healthcare or SNF setting.
• Strong interpersonal and communication skills.
• Knowledge of regulatory requirements related to discharge planning.

• Certification in Case Management or Discharge Planning is preferred.
• Familiarity with electronic health record systems.
• Ability to work collaboratively in a team-oriented environment.

Working Conditions

• Works in office area(s) as well as throughout the nursing service area (i.e., drug rooms, nurses’ stations, resident rooms, etc.).
• Moves intermittently during working hours.
• Is subject to frequent interruptions.
• Is involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.
• Is subject to hostile and emotionally upset residents, family members, personnel, and visitors.
• Communicate with the medical staff, nursing personnel, and other department directors.
• Works beyond normal working hours and on weekends and holidays when necessary.
• Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).
• Is involved in community/civic health matters/projects as appropriate.
• Attends and participates in continuing educational programs.
• Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday, as well as reactions from dust, disinfectants, tobacco smoke, and other air contaminants.
• Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS, COVID-19, and Hepatitis B viruses.
• May be subject to the handling of and exposure to hazardous chemicals.
• Maintains a liaison with the residents, their families, support departments, etc., to adequately plan for the residents’ needs.

Education

Must possess and maintain any and all necessary active and unencumbered certifications, degrees, or licenses in the necessary state, to the extent the position requires such certifications, degrees, or licenses.

Specific Requirements

• Must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served.
• Must be a supportive team member, contribute to and be an example of teamwork and team concept.
• Must possess the ability to make independent decisions when circumstances warrant such action.
• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.
• Must be able to relate information concerning a resident’s condition.
• Must not pose a direct threat to the health or safety of other individuals in the workplace.

Physical and Sensory Requirements (with or without reasonable accommodation)

(With or Without the Aid of Mechanical Devices)

• Must be able to move intermittently throughout the workday.
• Must be able to read, speak, and understandably write the English language.
• Must be able to cope with the mental and emotional stress of the position.
• Must function independently, and have flexibility, personal integrity, and the ability to work effectively with residents, personnel, and support agencies.
• Must meet the general health requirements set forth by the policies of this facility, which include a medical and physical examination if the position requires.
• Must be able to relate to and work with the ill, disabled, elderly, emotionally upset, and, at times, hostile people within the facility.
• Must be able to push, pull, move, and/or lift a minimum of 50 pounds to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 50 feet.
• May be necessary to assist in the evacuation of residents during emergencies.

All Other Duties as Assigned.

I understand this job description and its requirements; I understand that this is not an exclusive list of the job functions and that I am expected to complete all duties as assigned; I understand the job functions may be altered by management without notice and that I am an at-will employee.

Accommodations

The facility is an equal opportunity employer and recognizes that an individual with a disability may require accommodation to enable the individual to successfully perform a job function. I understand that I should discuss with my supervisor any needed accommodation. I agree to cooperate with the facility in identifying and discussing any available reasonable accommodation that may enable me to perform the essential function(s) of my position.