How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.
The Care Coordinator Social Worker will work in conjunction with the physician and other care team members to assess and plan for safe care delivery and transition planning to the next level of care. In conjunction with the physician, will assess, coordinates, and implements a timely, safe patient discharge plan to the appropriate level of care. Participates in interdisciplinary approach to patient care management. Provides emotional and psychosocial support to patients. Will partner and offer expertise guidance to the Care Coordinator RN of complex social determinants of health issues, situational dynamics and complex social needs.
Attends and actively participates in interdisciplinary team meetings to share and screen for high risk patients, obtain and share information, identify appropriate length of stay per DRG, advance the patient's plan of care, identify and act to resolve barriers and to coordinate safe and appropriate discharge to the proper level of care within the appropriate time frame. Maintains focus on the provision of quality service in a rapid and efficient manner to transition patients to the appropriate level of care within the time frame of the target length of stay. Updates the clinical team regarding discharge destination, and date and time of anticipated discharge.
The Care Coordinator Social Worker is responsible for selected functions related to Advance Directives, Resource identification and Disposition Planning across units at WellStar Health System, focusing on patients with acute and chronic care needs and plan for post discharge care needs in the community based on risk status. The duties include but are not limited to: Early case findings for discharge planning, assessment of patients and family's needs for postacute care and placement, transitions of care activities, post discharge follow up appointment, pharmaceutical applications, referrals to community resources and other services that may be required for the patient. Provides education to the community as needed. Documents in an accurate, timely and thorough manner in accordance with departmental policy.
The Care Coordinator Social Worker will participate in and or ensure that education on chronic care conditions, such as CHF or COPD or other CMS Readmission focus conditions are appropriately done by collaborating with the multidisciplinary team using established WellStar teaching tools.
Must work in close collaboration with UM Nurses. Review targets for LOS, target outcomes and discharge plans with the providers and family Collaborate effectively with the patient's health care team to establish an optimal discharge plan. Assure the patient is progressing toward discharge goals and assist to resolve barriers Attends the patient/family care conference and IDRs Assess and monitor patient's continued appropriateness for IP care and tracks avoidable days.
Required Minimum Education
Posted about 12 hours ago
Posted about 12 hours ago
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