Discharge Planner

The Discharge Planner for Millennium Physician Group is responsible for visiting patients at hospitals, assessing their needs, and determining if home care services are required to ensure a safe transition from hospital to home. The ideal candidate for this role is an LPN or Social worker with a strong understanding of patient care. The primary goal of the Discharge Planner is to prevent patients from being discharged from the hospital in an unsafe condition and facilitate their recovery and well-being at home.

Responsibilities:

Hospital Visits: Conduct regular visits to hospitals within the designated area to meet with patients who have been referred for discharge planning.

Meetings: To ensure work flow processes and collaboration of care is present. Measuring outcomes to ensure success of the program.

Patient Assessment: Assess the specific needs of each patient by thoroughly reviewing medical records, discussing with healthcare professionals, and evaluating patients' physical, emotional, and psychological conditions.

Home Care Evaluation: Determine whether the patient requires home care services, considering factors like the complexity of the patient's needs, available support systems, and potential risks associated with self-care.

Collaborative Care Planning: Collaborate with the patient's healthcare team to develop a comprehensive care plan that addresses the patient's specific needs, with a focus on ensuring a safe transition from the hospital to home. Ensure patients have a scheduled appointment with PCP after discharge and assist with transportation set up if necessary.

Resource Coordination: Facilitate the coordination of necessary resources, including durable medical equipment, medication management, skilled nursing care, therapies, and community services, to support patients' recovery and well-being.

Communication: Maintain regular communication with patients, their families, healthcare providers, and internal team members to ensure effective care coordination and address any concerns or changes in the patient's condition.

Education: Provide patients and their families with education on self-care, medication management, wound care, and any other necessary topics to promote a safe recovery at home.

Documentation: Accurately document all interactions, assessments, care plans, and interventions in accordance with company protocols and legal requirements.

Compliance: Adhere to all relevant regulations and guidelines related to patient care, privacy, and safety.

Continuous Improvement: Continuously monitor and assess the effectiveness of discharge plans, identifying any areas for improvement and implementing necessary changes to enhance patient outcomes.

Qualifications:

Education: Active LPN licensure or Social worker

Experience: Minimum 2 years of experience in healthcare, preferably with a focus on discharge planning or care coordination in a hospital or home care setting.

Knowledge: Strong understanding of patient care protocols, medical terminology, and the healthcare system.

Communication Skills: Excellent communication and interpersonal skills to effectively collaborate with patients, families, healthcare professionals, and internal team members.

Critical Thinking: Exceptional critical thinking and problem-solving abilities to assess patient needs, anticipate potential risks, and develop effective care plans.

Organization: Strong organizational skills with the ability to manage multiple tasks and prioritize responsibilities in a fast-paced environment.

Compassion: Demonstrated empathy, compassion, and ability to support patients and families through challenging times.

Technology: Proficient in using electronic medical records (EMR) systems and other software applications necessary for documentation and communication purposes.

Flexibility: Willingness to work flexible hours and travel to various hospitals within the designated area.

Ethics: Uphold the highest standards of ethics and professional conduct, maintaining patient confidentiality and privacy at all times.