Social Worker Discharge Planning

Northwestern Medicine; DeKalb Township (IL); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Benefits package

Job summary

Northwestern Medicine seeks a Social Worker for Discharge Planning to coordinate care from hospital admission through discharge for patients and families. The role emphasizes collaboration with physicians and the healthcare team to ensure safe, timely transitions and access to needed community resources.

The position requires a Bachelor’s degree in Social Work, at least two years of hospital discharge planning experience, and an LCSW credential.

Qualifications

• Bachelor’s degree in Social Work is required.
• At least two years of hospital discharge planning experience with direct patient services in acute care.
• Knowledge of growth and development across the lifespan.
• LCSW credential is required.

Responsibilities

• Coordinate discharge planning and social services to optimize patient outcomes.
• Collaborate with medical staff to develop smooth discharge plans for patients and families.
• Monitor clinical information to support assessment, treatment, education and continuity of care.
• Assist with insurance pre-certifications and utilization management as needed.
• Provide patient education on discharge planning and resources.
• Serve as a resource on mental health laws and directives.

Skills

Collaboration with healthcare team

Discharge planning experience

Education

Bachelor’s degree in Social Work

Job description

Description

The Social Worker Discharge Planning reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.

The Social Worker is responsible for providing high quality services through the continuum of care to the patient and the patient’s family in order to obtain optimal social and emotional functioning. These services include direct service to patients and their families both on an inpatient and outpatient basis. The Social Worker coordinates options and services to meet the patient’s needs through collaboration and consultation with physicians and other healthcare personnel.

Responsibilities

• Assure positive patient outcomes through coordinating the discharge planning and social service program identifying patients needing services after discharge with consideration given to normal characteristics of growth and development throughout the life span.
• Works collaboratively with the Medical Staff and other members of the healthcare team to ensure smooth transition and comprehensive discharge plans for their patient and their family.
• Monitors clinical information to support the assessment, treatment, education and continuity among healthcare providers and to enhance and improve individual and organizational performance in patient care.
• Institutes practice changes based upon findings from utilization review and utilization management benchmark data.
• Assures compliance with mandated Medicare/Medicaid initiatives.
• Acts as the hospital and community resource person to help people in the service area find appropriate services.
• Enhances and maintains an environment in which patient safety is a priority as evidenced by:
  • Identification of patients at high risk for need of discharge services or assistance
  • Use of SBAR and closed loop communication techniques
  • Practicing national patient safety goals
  • Maintains infection control standards
  • Protects client’s rights in accordance with the Illinois Mental Health code and all Healthcare laws.
• Coordinates with patient the activities to meet patient’s goals as evidenced by:
  • Working collaboratively as a member of the health care team and with the patient/family/significant other to develop a plan of continuing care compatible with patient needs, goals, and financial resources while giving consideration to the normal characteristics of growth and development throughout the life span. Documenting plan appropriately in Meditech and Midas.
  • Family/significant other participation in patient care per patient request/approval.
  • Complete all required forms in accordance with the Illinois Mental Health Code.
• Active participation with interdisciplinary team communication and conferencing supporting the formulation, implementation, evaluation, and revision of the plan of care specific to the patient. Documenting care appropriately
• Assists with progression of care with focus in which patient/family/significant other and the interdisciplinary team are aware of and working toward goals to meet the anticipated discharge date.
• Collaborates with interdisciplinary team to address need to move patient to a lower level of care, add/change/delete ancillary service, discharge a patient, change medication/treatment to a less expensive alternative, or provide education when appropriate.
• Identifies potential avoidable days, collaborates with the physician and nursing staff to address potential avoidable days. Documents avoidable days in MIDAS.
• Responds to all insurance reviews and requests in a timely manner.
• Complete insurance pre-certification for psychiatric transfers and DMEs as needed; document necessary insurance information in Meditech and/or MIDAS.
• Understands and supports organizational goals regarding resource utilization as evidenced by:
  • Functioning as a resource to physicians and hospital staff regarding mental health laws and psychiatric services.
  • Supporting and utilizing most effective staffing reflecting census/patient needs
  • Identifying cost-saving measures
• Anticipates barriers to patient progress toward goals and performs ongoing assessment to identify patients with discharge needs, or changes in patient discharge needs.
• Complete the transfer of patients to other hospitals with appropriate psychiatric facilities per Physician/Psychiatrist order or at the request of the patient/family. All transfers will be in accordance with EMTALA and Cobra laws and hospital policies.
• Provide referrals based on financial needs and funding.
• Complete insurance pre-certification for psychiatric transfers and DMEs as needed and document necessary insurance information in the patient’s record.
• Provide ongoing patient education including:
  • Assessment of learning needs, abilities, preferences, and readiness
  • Providing education relating to discharge planning, options, resources, utilization management, advance directives
  • Providing for informed patient decision-making regarding above topics
• Serves as a resource for those seeking information about services and care available in the surrounding community area and assists people in finding information/resources for services that are available in distant areas.
• Responds to Code 999, when present in the Hospital:
  • Assist in the de-escalation of behavioral patients
  • Assist in the medical staff to secure the safety of the patients to include restraints as needed.
  • Documentation of all interventions within a code 999 to include restraints and debriefing with the medical staff.
• Responds to Code Blue and Rapid Response, when present in the Hospital:
  • Assist with the communication and supportive services to all present family
  • Contact family via phone to communicate any current medical status and provide supportive services.
  • Assist the medical staff to coordinate appropriate resources for family to include housing or local services.
• Documentation of all interventions within the code and services provided. Recognizes, responds, provides education and appropriately refers requests for problem intervention to include, but not limited to:
• Recognizes, responds, and appropriately refers requests for problem intervention in accordance to the Illinois Mental Health and Developmental Disabilities Code to include:
• Acts as a resource to patients, community, and interdisciplinary team for mental Health Laws and advanced directives.

Qualifications

Minimum Requirements

Education:

• Bachelor’s degree in Social Work

Experience:

• At least two years of hospital experience in discharge planning with documented experience in acute care setting providing direct service to patients
• Knowledge of normal characteristics of growth and development throughout the span of life.
• LCSW

Equal Opportunity

Northwestern Medicine is an equal opportunity employer (disability, VETS) and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.

Background Check

Northwestern Medicine conducts a background check that includes criminal history on newly hired team members and, at times, internal transfers. If you are offered a position with us, you will be required to complete an authorization and disclosure form that gives Northwestern Medicine permission to run the background check. Results are evaluated on a case-by-case basis, and we follow all local, state, and federal laws, including the Illinois Health Care Worker Background Check Act.

Artificial Intelligence Disclosure

Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person.

Benefits

We offer a wide range of benefits that provide employees with tools and resources to improve their physical, emotional, and financial well-being while providing protection for unexpected life events.

Click on or copy and paste URL to your browser to view detailed benefits information https://jobs.nm.org/benefits

Please refer to the Benefits Eligibility by Employment Classification to determine benefits eligibility for job postings.

If sign-on bonus is included in a job posting eligibility is as followed:

Internal employees and rehires who left Northwestern Medicine within 1 year are not eligible for the sign-on bonus. Exception: New graduate internal employees seeking their first licensed clinical position as a Registered Nurse at NM may be eligible.