Discharge Plan Manager - RN or SW - Casual

UPMC is seeking a Casual Discharge Plan Manager. This role primarily involves working the day shift but may include some evenings until 8:00 p.m., as well as occasional weekends and holidays. Flexibility is a key requirement.

The Discharge Plan Manager coordinates and is accountable for all post-discharge needs, acting as a financial steward for the hospital. This role involves assessing relevant factors, engaging with the care team, and focusing on an optimal discharge plan that ensures timely utilization of hospital resources. The optimal discharge plan reviews discipline recommendations and coordinates necessary care for positive patient outcomes outside of the inpatient setting.

Responsibilities:

• Identify clinical, psychosocial, historical, financial, cultural, and spiritual needs that guide the planning process with the patient to achieve optimal outcomes. Consider the patient/family/caregiver’s level of health literacy.
• Evaluate the patient/family/caregiver’s understanding and engagement with progress toward goals, incorporating findings into the plan of care. Balance resources with patient preferences and goals of care.
• Assess the potential impact of social determinants of health that may elevate the risk of a poor transition.
• Complete detailed assessments on every patient to understand medical and social factors, determine the patient’s capacity for self-care, identify support systems, outline barriers to discharge, and determine the likelihood of requiring post-hospital services and their availability. Continually reassess the discharge plan for factors that may affect continuing care needs or the appropriateness of the discharge plan.
• Facilitate teams to develop and execute safe and efficient discharges. Maintain knowledge about area resources, their capabilities, and capacities, as well as various types of service providers available. Ensure appropriate arrangements for post-hospital care are made before discharge to avoid unnecessary delays.
• Integrate patients’ goals, the healthcare team’s assessment, risks, and available resources to develop and coordinate a successful transition plan.
• Engage in clear communication with the patient/member/caregivers and the interdisciplinary care team to develop discharge plans. Serve as a liaison between the patient and the care team.
• Actively collaborate with the attending practitioner, caregivers, and other members of the multidisciplinary team to coordinate an individualized plan of care. Incorporate discipline-specific recommendations, test results, and outstanding orders into the discharge plan, and monitor, revise, and respond to the progression of discharge milestones.
• Serve as a contact between hospitals and post-hospital care facilities, as well as the physicians who provide care in either or both settings.
• Recognize and demonstrate shared accountability in developing a discharge plan with the patient/member/caregiver and team members to ensure optimal outcomes.
• Align practice with the mission, vision, and values of the organization. Adhere to ethical standards and codes of conduct of applicable professional organizations and UPMC. Maintain clinical knowledge and ensure compliance with regulatory requirements.
• Advocate on behalf of patients/family/caregivers for service access and the protection of the patient’s health, well-being, safety, and rights.
• Manage the cost of care with the benefits of patient safety, clinical quality, risk, and patient satisfaction to provide recommendations and decisions that ensure optimal outcomes.
• Embrace and incorporate innovation and technology to improve collaboration and patient outcomes. Document care in the patient medical chart.
• Provide staff orientation and mentoring as appropriate.