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Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations.
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Collaborates with and completes referrals to appropriate community agencies for assistance based on patient need. Initiates referrals in a timely manner. Uses responses to help patient resume life in the community and/or adjust to lifestyle changes.
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Communicates daily with direct caregivers and case management triad regarding patient and family responses to plan of care, identification of problems, discharge planning, and payor concerns such as LOS. Identifies delays in care and quality/risk issues and communicates information to appropriate individuals and departments.
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Completes psychosocial history or socioeconomic assessment as determined by healthcare team or high-risk indicators.
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Coordinates the completion of requisite forms by doctors, patients, and patients' families for any services required. Maintains accurate and timely documentation of case management activities to assure that physicians and caregivers are well informed regarding the discharge plans. Adheres to all policies and procedures regarding documentation and confidentiality of information.
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Demonstrates knowledge of the dynamics of abuse/neglect, including identification and reporting laws. Coordinates with investigating law enforcement, protection agencies, hospital security, risk management, and healthcare team. Demonstrates knowledge of community resources serving the high social risk populations.
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Develops and maintains information on community resources and referral requirements based on patient population as identified in the unit scope of practice.
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Facilitates communication between the patient and family and the healthcare team. Assesses and communicates the patient's social, cultural, emotional, and economic problems to medical staff and other healthcare providers as needed. Effectively intervenes with patient/family in resolving emotional/behavioral obstacles to patient's progress, recovery, and disposition.
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Initiates and participates in multidisciplinary discharge planning rounds and collaborates with internal and external health care providers, patient and family to develop comprehensive discharge plans.
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Maintains own professional growth in the area of managed care, care management, other health care, financial trends, clinical practice and research.
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Organizes individual workload and sets appropriate priorities based on patient's medical plan, patient's needs, and policy and procedures.
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Provides crisis intervention and management.
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Participates in meetings and on committees and represents the department and hospital in community outreach efforts.
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Participates in multidisciplinary quality and service improvement teams.
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Performs other duties as assigned.