Discharge Planner/Utilization Review - FT

Discharge Planner and SB Coordinator Job Descriptions:

DISCHARGE PLANNER

POSITION SUMMARY:

To assist Medical, Nursing and other healthcare personnel in arranging for prescribed medical alternative treatment when the patient is discharged from the hospital to promote continuity of care. To assist patient and their families in decision making regarding providing the best possible level of care with least restrictions of the patient, whether the service provided is to be continued in home care or out-of-home care setting. This should provide provision for, or referrals to services that may be required to improve or maintain the patients health status. To assist patients and their families in arranging for placement or other plans of care, as needed for the patient when discharged from the hospital to promote continuity of care. Participates in patient care transitions process, including discharge/transfer instruction education of the patient both prior to and after discharge from hospital. Must be able to work well with minimal supervision. Works throughout the hospital with a work area provided in Case Management office. Consults with a qualified Social Worker or Certified Case Manager as needed.

PRIMARY RESPONSIBILITIES & AUTHORITIES:

• Obtain admission office information on all patients (patient census record) and screen them according to criteria developed and approved by LHHS Critical Access Hospital.
• Assist the Medical Staff in initiating a plan for post-hospitalization care of the patient when indicated.
• Plan for post-hospital care, which may include arranging for placement in skilled, intermediate, personal

Care, assisted living facilities and/or care in the home (Home Health, Hospices, etc.).

• Works with the patient/family/caregiver and physician to help decide appropriate discharge plans and make referral to appropriate agency. Enables patient and their families to understand, accept and follow medical recommendations through individual or group conferences.
• Receive referral from physicians, nursing staff or any other department of the hospital who observes patient needs and discusses with healthcare team members aspects of patients care to assist with planning the best level of care with least restrictions after discharge.
• Interview patients and/or families in securing background information and evaluating factors significant in providing continued patient care. Performs social assessments for care transitions. Interviews patients/family members/primary care provider of the patient to obtain information about living conditions, financial, social, emotional environments of the patient.

• Contacts community resources, such as senior citizens center and other pertinent sources, such as durable medical equipment companies, in order to mobilize environmental services on the patients behalf.
• Communicate regularly with hospital personnel on progress of continued plan of care.
• Provide patient teaching with appropriate reading/comprehension level to enable understanding of medical recommendations.
• Assists nursing staff with hospital discharge process of a patient.
• Make adequate, concise entries in the patients medical record in an effort to promote regular communications with physicians, nurses and other personnel involved in the patients care.
• Keep patient and/or family members informed of updates regarding transition/discharge plan.
• Follow-up call with high-risk and designated patients post-hospitalization to provide problem solving and intervention to prevent potential preventable re-hospitalizations. Maintains responsibility for post-hospitalization care plan (discharge instructions) to be provided to after-hospital medical services, including primary physicians and specialists.
• Assists nursing staff with initiating and obtaining necessary documentation and provision of documents (history, progress notes, MAR, labs, etc.) and patient information to complete a seamless patient level of care transition according to policies.
• Maintain work area in a clean and will organized manner.
• Develops and maintains good working relationships with other hospital personnel, community health, welfare and social agencies.
• Maintain confidentiality of all information obtained during performance of duties accordance to facility HIPPA rules.

OTHER DUTIES AND RESPONSIBILITIES:

• Other duties and responsibilities as directed by the Case Management Director and/or Chief Nursing Officer.
• Participates in the Quality Improvement Program of the facility as required.
• Assists with performance of other related work such as level of care criteria Utilization Reviews and documentation when needed.
• Assists utilization review coordinator or case manager with inpatient/observation/outpatient procedural authorizations when needed.
• Participates in taking call on afterhours and weekends, for purposes of monitoring patient level of care criteria and discharge planning needs for inpatient, outpatient and emergency department areas.
• Formulates with the Activity Director, when indicated, a social plan that meets the Swingbed patients needs.

MINIMUM QUALIFICAIONS (EDUCATION, EXPERIENCE, SKILLS, ABILITIES)

• Must be a graduate from an accredited school of nursing or social work with previous experience in the healthcare field setting.
• Competency should be reached within 90 days, Proficiency 6 months, and expertise within 2 years.
• Knowledge base of various computer software and use of computers necessary. Excellent communication skills, verbal and written are mandatory.
• Must display an ability to build positive relationships with patients/caregivers and hospital staff.
• Must be organized and able to perform duties with minimal supervision.

OTHER SPECIAL REQUIREMENTS (LICENSES, CERTIFICATIONS, REGISTRATIONS, ETC.)

• Must hold and maintain current, valid license under the educational setting in which it was obtained (ex: RN, LPN, LVN, CSW, etc.).
• Must have previous experience in the Healthcare field setting.

PHYSICAL DEMANDS:

• May require sitting or standing for long periods of time.
• Some bending, stretching and/or lifting may be required.
• Many back and forth trips between Case Management office and patient rooms/nurses station throughout the day.
• Ability to use hands for typing and updating medical records.

WORK ENVIRONMENT:

• Work is typically performed in an adequately lighted and climate controlled setting.
• May come in contact with body fluids, blood and various infectious diseases while interacting with patients.

SWING BED ACTIVITIES COORDINATOR

POSITION SUMMARY:

The Activity Coordinator/Designee is an important member of the health care team. Patient Activities are another modality in the total care plans that specifically address the individual patient problems/needs and help the team meet the care goals for that person.

PRIMARY RESPONSIBILITIES & AUTHORITIES:

1. Assess the patients psychosocial and spiritual needs and interest.

2. Assist the health care team to identify the social and spiritual needs of the patient.

3. Collaborate in the development of a plan of care incorporating activity goals and interventions for the identified physical and psychosocial problems.

4. Develop and implement individual and/or small group activities to achieve identified goals congruent with the physicians plan of care.

5. Coordinate activities with other patient services.

6. Interpret activity program to patients, families, and staff to gain appreciation and cooperation.

7. Maintain a current record of the patients planned activities.

8. Document the patients response to the plan, (i.e. achieving the treatment goals).

9. Facilitate patients participation in activities to meet the needs of each patient.

10. Supervise and coordinate volunteers to assist with activities program implementation if the facility has such a program.

11. Defines in-service needs to the consultant for growth and professional development.

OTHER DUTIES AND RESPONSIBILITIES:

N/A

MINIMUM QUALIFICATIONS (EDUCATION, EXPERIENCE, SKILLS, ABILITIES):

1. A Patient Activities Coordinator is a staff member who has had at least two years experience in social or institutional program/patient care in the last five years; one year which was full time in a patient activity program in a health care setting or be willing to undergo training as an activities director.

2. A Patient Activities Designee is a member of the facility staff that has been designated as a person responsible for the patient activity program function with frequent, regularly scheduled consultation from a consultant. The consultant must have certification as an activity director in the state of Kentucky, or directly practice under the direction of a consultant with this certification.

OTHER SPECIAL REQUIREMENTS (LICENSES, CERTIFICATIONS, REGISTRATIONS, ETC.)

• The consultant must have certification as an activity director in the state of Kentucky, or directly practice under the direction of a consultant with this certification.

PHYSICAL DEMANDS:

May require sitting for long periods of time. Also, may require some lifting, pulling and standing while assisting with patient care. May require walking for errands. Ability to use hands for typing and updating medical records.

WORK ENVIRONMENT:

Well-ventilated, and well-lighted areas. May be in contact with body fluids, blood and various infectious diseases when coming in contact with patients. May organize outdoor activities weather permitting.