Discharge Planner - Home Care jobs in Columbus, GA

This individual works closely with new admissions to the Rehab Center to ensure medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. “Medically -related social services means services provided by the facility’s staff to assist residents in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs”. Also ensures that patients are prepared for a safe and appropriate discharge from the Rehab Center.

This individual also assists and backs up the Admission Coordinator as required with admission paperwork, admission meetings and tours.

This individual also assists and backs up the Rehab MDS Coordinator for insurance processes including prior authorizations, updates, etc…

Duties:

• Makes initial contact with patient within 24 hours of admission and documents contact in a social service progress note.
• Inform patients and provide written information concerning the right to accept or refuse medical or surgical treatment and at the individual’s option, to formulate an advance directive. Address advance medical directives in each quarterly review.
• Provide patient and a family member or legal representative notice in writing regarding bed hold policy before transfer and at the time of the transfer.
• Complete comprehensive assessments, in conjunction with Multidisciplinary Care Team, of patient’s needs using policies and procedures specified by the state.
• Develop comprehensive care plans for each patient in conjunction with the Multidisciplinary Care Team that include measurable objectives and timetables to meet the resident’s medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment.
• Provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. “Medically -related social services means services provided by the facility’s staff to assist patients in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs”.
• Promote care for patients in a manner and in an environment that maintains and enhances each patient’s dignity, respect, and quality of life in full recognition of his or her individuality.
• Complete quarterly reviews and updates of patient assessments.
• Complete annual assessments within 366 days after completion of the most recent comprehensive resident assessment.
• Provide orientation for transfer or discharge in conjunction with other members of the care team to prepare resident and ensure safe and orderly transfer or discharge from the facility.
• Document social services contacts, activities, assessments, care plans, reviews, etc. in social services progress notes and/or other appropriate forms in the medical record in a timely manner.
• Participate in periodic professional development opportunities within and without the facility to ensure continuing competence, to maintain or obtain appropriate licenses, and/or to target staff development needs.
• Assists Admission Coordinator with Admission Meetings and with tours as required.
• All other duties as assigned.