Performs and executes discharge planning
- Develops sound and reliable discharge plans incorporating risk for readmission assessment in discharge needs and support structure
- Includes all stakeholders in the discharge plan to ensure plan is sound and fully communicated
- Participates in multidisciplinary rounding process as requested
- Works collaboratively with all caregivers in the continuum of care to ensure sound and timely discharge plan
- Demonstrates strong understanding and mastery of community resources
- Possesses strong discharge planning assessment skills
- Communicates well and frequent with patient and family
- Works collaboratively with nursing and other members of the care team, to ensure issues that Case Management identifies, are included in the plan of care
- Organizes and leads multidisciplinary care conferences as necessary to facilitate plan of care progression.
- Ability to identify barriers to transportation and assist with getting patient transportation to appointments
- Provide ongoing recovery support service to ensure patient arrives and is engaged by intake staff, and ensure that patient remains engaged in treatment overtime – helping the patient navigate stages of change and practical considerations.
- Work with insurance provided transportation programs to ensure transportation
Ensures Patients receive comprehensive services: Assists the interdisciplinary treatment team in patient assessment for appropriateness of treatment services.
Is knowledgeable and capable of working with patients who present a dual problem, Co-
- Occurring Substance Use and Mental Health Disorder.
- Provides that all patient contact and interaction is based upon inherent dignity, individuality, culture and beliefs of each patient. Patient care is provided in a compassionate, humane, and non-enabling manner.
- Participates in interdisciplinary clinical staffing or ensures pertinent information is provided to team
- Demonstrates Motivational Interviewing skills when working with patients.
- Demonstrates ongoing assessment for next level of care and actions to move patient to appropriate level
Assist in facilitation of services, based on quality initiatives and documentation in EMR
- Ensures accurate documentation
- Collaborates with Certified Peer Recovery Specialist and Data Analyst to ensure documentation is present to supports warm hand off.
- Documents all Discharge Planning components accurately in EMR
- Assist with documentation in EMR to support quality initiatives
- Assist with audits for medical necessity documents as requested
Basic UPH Performance Criteria
- Demonstrates the UnityPoint Health Values and Standards of Behaviors as well as adheres to policies and procedures and safety guidelines.
- Demonstrates ability to meet business needs of department with regular, reliable attendance.
- Employee maintains current licenses and/or certifications required for the position.
- Practices and reflects knowledge of HIPAA, TJC, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.
- Completes all annual education and competency requirements within the calendar year.
Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse. Brings any questions or concerns regarding compliance to the immediate attention of hospital administrative staff. Takes appropriate action on concerns reported by department staff related to complianc