Social Worker, Penn Medicine, University of Pennsylvania Health System

Posted by University of Pennsylvania Health System on May 26, 2020

Location: West Chester, PA

Responsible for coordinating all post-acute services for inpatients and outpatients. Interviews patients and families, assesses aftercare options and provides information, guidance and support in decision-making. Provides emotional support and counseling to caregivers. Assists patients and families with application to financial aid programs. Collaborates with peers, physicians, other departments and community agencies to expedite placements. Works with patient and family to help them understand the impact their illness may/will have on their lifestyle, family relationships and home situation.

Essential Duties And Responsibilities

Discharge Planning Competencies

  • Interviews and collaborates with patient/family to assess aftercare options providing guidance information and support in decision making.
  • Coordinates all aspects of the discharge process for patients with complex post-acute needs returning home.
  • Develops alternative discharge plans and coordinates with Team Leader, peers, and Case Manager as needed to facilitate resolution of problem dispositions or difficult patients/families.
  • Facilitates and monitors the discharge plans and arrangements for assigned patients going to boarding homes, assisted living homes, skilled care, long term care, hospice, or rehabilitation (physical, psychiatric, drug and/or alcohol).
  • Refers to community services as needed, including (but not limited to): office of aging, CYS, CVIM, MH/IDD, crisis, domestic violence, dialysis services, VNA, etc.
  • Works with patients and their families to help them understand the impact their illness may have on their lifestyle, family, relationships and home situation.
  • Coordinates individual patient care conferences when deemed necessary, including appropriate inpatient and outpatient personnel/agencies.
  • Develops a discharge plan in a timely manner to maintain lowest cost to the hospital, while ensuring a comprehensive quality plan.
  • Procures signature on second Medicare Important Message (IMM) form for assigned patients as required by CMS 48 hours prior to discharge.

Intervention Competencies

  • Discusses the plan of care and targeted length of stay with the multidisciplinary team, patients, and family at the time of admission.
  • Explores strategies to reduce the length of stay and resource consumption.
  • Serves as a patient advocate with the health care team, payors and outside agencies.
  • Collaborates with primary nurses to identify plans to maintain streamlined patient care.
  • Participates in the daily discharge rapid rounds (multidisciplinary team meetings) coming prepared with essential information.
  • Identifies a plan with the Case Management Director and/or Team Leader to address system opportunities and participates in that plan.

Communication Competencies

  • Communicates patient needs to medical staff, nursing staff, Case Management team, as appropriate.
  • Communicates patient needs, with attention to details, to service providers to insure safe level of care and appropriate resources after discharge.
  • Communicates with medical staff regarding case management issues as they occur and document in Soarian Clinicals.
  • Communicates with ancillary departments to negotiate accelerated test scheduling to receive results not yet available on medical record in Soarian Clinicals, or ensure interaction with patient as ordered by physician.

Documentation Competencies

  • Records all patient/family activity, interaction or intervention related to discharge planning on the medical record using the Soarian Clinical system.
  • Documents action taken related to discharge planning within same day of interaction with patient/family and/or physician.

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