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Serves as a hospital/post acute-based leader for comprehensive case management activities including assessing high-risk patients and leading team to identify at-risk patients, participating in daily Care Coordination rounds, and identifying and leading resolution to barriers of efficient patient throughput.
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Uses knowledge for different levels of care, working with patient and family, to ensure discharge disposition is to the appropriate level and facilitates transfers, Provides brief, goal-directed counseling services to assist patients/families to cope more effectively with the transition.
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Consistently reviews the total picture of the patient for opportunities for care facilitation and needs for discharge planning. Provides education to physicians and other interprofessional health care team members on mutually identified goals of care and uses knowledge of levels of care, working with patient and family, to ensure discharge disposition is the appropriate level and facilitates transfers.
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Guides discharge planning activities for assigned patients and collaborates with the case managers and other members of the interprofessional health care team, as well as patient and family by intervening and coordinating cost-effective, complex discharge planning outcomes and decreased length of stay.
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Establishes mutual educational goals with patient and family, providing appropriate resources, incorporating planning for care after discharge. This position serves as a hospital-wide, service-line leader for psychosocial related issues, complex discharge planning activities, and population disease management.
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The SW II position holds joint accountability with case manager, assuring that psychosocial and continuing care issues are addressed and treated as needed across the continuum of care and has responsibility for unit or departmental social work program development.
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At Houston Methodist, the Social Worker II (SW II) position comprehensively provides compassionate, clinical social work, psychosocial assessments, diagnosis and treatments, and complex discharge planning to patients and their families of a targeted patient population on a designated unit(s.
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Completes a full assessment based on the social work assessment, leading and addressing solutions of social determinants which is accomplished by patient/family interview, review of the medical record including previous episodes of care, H&P, lab and other test results/findings, plan of care, physician orders, nursing and progress notes.
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Works with case manager for routine discharge and anticipates/prevents and manages/elevates emergent situations with specific focus given to discharge plan and elimination of psychosocial barriers.
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Uses therapeutic communication to establish a relationship with patients and families and communicates the discharge plan, facilitating transitions and hand-offs. + Collaborates with staff from the interprofessional health care team concerning safety data to improve outcomes and the safe transition of care through effective patient handoffs.
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C-SWHC - Certified Social Worker in Health Care (NASW) Modifies care based on continuous evaluation of the patient's condition, demonstrates problem-solving and critical thinking, and makes decisions using evidence-based analytical approach.
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Role models communication in an active, positive and effective manner to all health care team members and reports pertinent patient care and family data in a comprehensive and unbiased manner, listens and responds to the ideas of others.
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The Physical Therapist will practice within defined standards of care and direct the practice of support staff in order to achieve the patient's functional and discharge goals. Participates in the development of individual discharge plans that are responsive to patient/family concerns.
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Our 291-bed, acute care hospital features the San Diego Spine & Joint Center, a highly credentialed acute rehabilitation center, our Paradise Health & Senior Center, a fully equipped and modern cardiac catheterization lab, and comprehensive inpatient and outpatient surgical services, and 24-hour emergency services.
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The Psychiatrist at Hampstead is a key role that involves assuming responsibility for the admission, continuing care, and discharge of patients at the Hampstead Hospital and Residential Treatment Facility (HHRTF.
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acute care discharge jobs
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