Social Services/Discharge Planner

Description

The responsibility of the Social Services/Discharge Planner is to act as an advocate for the residents. The Social Services/Discharge Planner protects vulnerable residents and ensures that their best interest is observed and helps them to find remedies to their situation. The Social Services/Discharge Planner also holds the responsibility of monitoring and completing the steps of residents' discharges.

Note: All employees of Cascadia Healthcare are required to submit and be cleared to work in the facility per each 

state’s specific background check requirements prior to contact with patients/residents.

Essential Functions

• Assesses the psychosocial status of patients related to the patient’s illness and environment and communicates findings to the registered nurse. 
• Performs the tasks of a discharge planner working with families, patients, physicians and staff to ensure proper documentation and orders are in place and patients have everything they need for a successful discharge.
• Actively participates in discharge planning and advises on issues relating to resident’s/patient’s practical and enviro mental needs post-discharge.
• Carries out social evaluations and plans person-centered intervention based on evaluation findings. 
• Maintains clinical documentation on all patients referred to social work. 
• Provides information and coordinates referral services for residents/patients and families/caregivers regarding resident’s/patient’s practical and environmental needs. 
• Provides information to residents/patients or families/caregivers regarding community agencies and other available services. 
• Serves as liaison between residents/patients or families/caregivers and community agencies. 
• Maintains collaborative relationships with facility co-workers to support resident/patient care. 
• Participates in the development of the total plan of care and case conferences for residents/patients referred to social services, as required. 
• Assists physician and other team members in understanding significant social and emotional factors related to residents’/patients’ health problems.
• Addresses resident behaviors to prevent harm to themselves or others. 
• Coordinates medication review regimen to determine gradual dose reduction to the lowest possible dose.

Knowledge/Skills/Abilities

• Demonstrates good verbal and written communication, and organization skills.

Requirements

Licenses/Certification

• LCSW, LSW, or MSW license preferred.
• Must have a valid driver’s license.

Experience

• Experience in post-acute/ skilled nursing preferred.