Discharge Planning Coordinator - LVN - Case Management - Per Diem ; Non-Exempt; Union

Overview

Provides department support for the Continuum of Care Team to facilitate discharge planning and ensure appropriate throughput of patients. Works with Case Managers, Transitional Care Coordinator, and Social Workers to ensure discharge plans are communicated to patients and families during hospitalization and post discharge to ensure continuity and identify clinical barriers. Enables a positive patient experience through the discharge process and connection to resources as needed.

• Partners with members of the Continuum of Care team (case managers and social workers) to provide patients and families a smooth, coordinated transition from hospital to home and/or the next level of care.
• Collaborates with the Care Coordination team to ensure timely communication at discharge so the patient’s transition is smooth; provides timely post-acute contact and reinforces post-discharge instructions under the direction of the Transitional Care Coordinator.
• Under the direction of the Transitional Care Coordinator, utilizes referral platforms (e.g., Enso care, e-fax, phone calls) to review post-acute referrals; reviews discharge instructions and discharge summaries to understand the post-acute plan of care and barriers to follow-up; provides timely follow-up on all referrals.
• Participates in post-discharge phone calls to patients using scripts and the Cipher Health communication approach as directed by the Transitional Care Coordinator.
• Communicates frequently with clinic physician staff and other post-acute providers as needed to support discharged patients with identified needs.
• Follows established policies, procedures, and workflows for post-discharge phone calls.
• Communicates the discharge plan and status to Continuum of Care team members and participates in triad huddles and triad team task provisioning.
• Contacts post-acute care facilities to assess bed availability and submission of referrals; uses multiple referral platforms to facilitate referrals.
• Coordinates non-clinical aspects of the discharge process (e.g., durable medical equipment, housing resources, non-clinical letters, transportation) reporting psychosocial needs or barriers to the appropriate Continuum of Care team member.
• Maintains frequent, direct communication with Continuum of Care team members regarding discharge needs and priorities; relays orders to the appropriate case manager and collaborates with the Triad team for daily assignments.
• Participates in departmental meetings, daily huddles, triad huddles, and Continuum of Care team meetings.
• Uses tools (e.g., Medicare.gov, patient choice tablets) to provide patients with skilled nursing facilities and/or discharge planning resources within 10 miles or close to the patient’s home.
• Documents appropriately following departmental standards in the electronic Medical Record.
• Assists with transfer of patients for lateral and/or acute services.
• Supports the Continuum of Care team with arranging transportation (taxi, rideshare, ambulance) as needed.
• Assists with maintaining and updating current post-acute care resources (pamphlets and brochures).
• Participates in continuous improvement activities, including huddles and process improvement projects.
• Follows all departmental standard work and guidelines including the Triad Model of Discharge Planning and supports transitions of care.
• Develops and maintains positive relationships with outside post-acute facilities and vendors to promote timely discharge/transfer.
• Thrives in a fast-paced, multi-faceted team environment, meets tight deadlines, and multitasks effectively.
• Supports the Continuum of Care team’s outcome metrics and departmental goals and objectives.
• Represents the department in a positive and professional manner.
• Floating between assignments and hospitals is required; on-call, weekend coverage, and rotation to manage discharge needs are expected.
• Supports the clinical process for transfer between levels of care as medically indicated, applying clinical knowledge to reference Inter Qual Discharge Screens and determine discharge/transition suitability.
• Completes clinical authorization for discharge medications.
• Perfo…