Key Responsibilities / Essential Functions

1. Proactively identifies or receives referrals for patients who are likely to be in need of discharge planning assistance
2. Completes initial and ongoing assessment of patients’ discharge needs.
3. Develops discharge plan based on the assessment and agreed upon goals with the patient, family and interdisciplinary healthcare team.
4. Contributes to the interdisciplinary plan of care and ensures that the plan is consistent with the discharge plan and patients continuing care needs.
5. Makes timely referrals to appropriate community services based on identified needs that assure continuity of care through the discharge planning process.
6. Ensures timely completion of all discharge, transfer, and referral forms.
7. Evaluates the effectiveness of interventions in relation to the intended goals and makes revisions in the discharge plan as necessary.
8. Ensures that cases of abuse/neglect are reported to the Department of Human Resources.
9. Assesses the need for and processes requests for indigent programs and assistance.
10. Participates in interdisciplinary patient meetings on assigned units to identify and coordinate the elimination of barriers to efficient discharge.
11. Ensures that all critical elements of the discharge plan are communicated to the patient or caregiver and are documented in the medical record.
12. Assures that documentation consistently meets department and organizational standards.
13. Demonstrates a high degree of skill and professionalism in all oral and written communications and personal interactions.
14. Provides effective on call coverage and crises intervention that responds to the needs of patients, families and hospital team members.
15. Demonstrates the ability to effectively problem solve in a crises situation.
16. Consistently complies with department and organizational policies including attendance, behavior, dress code, productivity and required meetings.
17. Attends Department and Team staff meetings. Must attend at least ¾ of scheduled meetings.
18. Demonstrates initiative and accountability in maintaining professional growth.
19. Complies with organizational and Social Worker Code of Ethics including educational requirements and licensure.
20. Maintains absolute adherence to hospital and departmental policies regarding confidentiality and patient’s rights.
21. Perform additional duties as assigned.