Discharge Planning Specialist

Purchaseyourfreedom; Oakville; Hybrid; CAD 65,000 - 84,000; Full time

Job summary

Halton Healthcare is seeking a Social Work Discharge Planner to support in-patient units across Oakville, Milton and Georgetown. You will coordinate discharge plans, address barriers, and collaborate with an interdisciplinary team to ensure patients are in the right place at the right time for the right care.

The role requires BScN/BSW/MSW, active registration, and 2–5 years in acute care with community/gerontology experience. Strong knowledge of resources and health legislation is essential.

Qualifications

• BScN or BSW or MSW required.
• Current registration and membership in good standing with respective regulated College (OCSWSSW, ONA).
• 2-5 year clinical experience in an acute care hospital setting.
• Minimum of three years, including community work and/or gerontology, discharge planning.
• Current knowledge of community resources and initiative to proactively search for new resources.
• Experience with legislation that governs Public Hospitals (Public Hospitals Act, Substitute Decisions Act, Consent to Treatment Act, etc.).
• Extensive knowledge of resources in public/private sectors, and medical/clinical language and procedures.
• Extensive knowledge of the impact of social determinants of health on discharge planning, LOS, Patient Flow and hospital capacity.

Responsibilities

• Coordination, formulation/development, documentation, and implementation of care plan for hospital discharge and safe transition back to community or institutional setting.
• Identification of both short and long term goals to ensure/enhance continuity of care for patient/family.
• Ensure plan is communicated to all stakeholders and that appropriate referrals have been processed and received
• Ensure that patient and/or SDM understands the discharge plan and has the relevant contact information for community partners.
• Ensure efficient use of hospital and community resources
• Early identification of patients requiring complex discharge planning case management through high risk screening criteria, consultation with team members and referrals.
• Planning, review and communication of plans and time lines in partnership with the multidisciplinary team, client/SDM, family, and community agencies/facilities.
• Facilitation of safe patient discharge through: case coordination and development of appropriate discharge plan.Included but not limited to: patient/family education; referral and completion of application to community services; coordination of legal/financial capacity or SDM issues including potential PGT involvement.
• Advocate to identify gaps in services, need for individualized program consideration and system level changes required to meet changing needs of patient population.

Skills

Expert communication

Collaboration

Organizational skills

Problem solving

Education

BScN / BSW / MSW

Registration with College (OCSWSSW/ONA)

Job description

Halton Healthcare is seeking a Social Work Discharge Planner to support in-patient units across Oakville, Milton and Georgetown. You will coordinate discharge plans, address barriers, and collaborate with an interdisciplinary team to ensure patients are in the right place at the right time for the right care.

The role requires BScN/BSW/MSW, active registration, and 2–5 years in acute care with community/gerontology experience. Strong knowledge of resources and health legislation is essential.