Responsible for, and will participate in, the assessment, planning, implementing, coordinating, communicating, and finalizing the discharge of the patient/resident from the hospital setting or rehab and nursing center. Works with other members of the health care team both inpatient and outpatient, to advocate for and ensure appropriate aftercare and follow-up.
Competently gathers information using assessment skills to identify physical, psychosocial, financial, and environmental health care needs of the patient/resident. Assess and identify appropriate resource utilization, level of care, and treatment options to develop a plan of care that will impact quality outcomes in a cost-effective manner.
Collaborates with the patient/resident, family, and health care team to promote quality care, prevent delay in discharge and complications to improve outcomes. Work with the patient and physician to develop a plan of care that meets their needs and will avoid duplication and or fragmentation of services. Ensure appropriate use of ancillary services providing guidance and direction and implementing modification to the plan of care as needed.
Efficiently documents assessments, clinical findings, completed tasks, plan for treatment, and progress toward goals for discharge. Keep accurate records of patient/family contact and team consultation. Works to actively facilitate an appropriate level of care for discharge and educate the patient on the progress of the discharge plan and the safety and benefits of the plan.
Monitor, evaluate, and coordinate referrals from multiple sources, while measuring patient care outcomes, interpreting reports, and addressing data from sources to better serve and impact the patient and their adjustment to illness and treatment.
Actively promotes frequent communication between all team members, providers, patients and family members to ensure a smooth transition from one level of care to another. Share and educate on community resources, support systems, and available benefits. Maintain communication with providers delivering care to ensure consistency in communication to patient/resident and family.
Demonstrate self-directed, self-motivated, responsible behavior recognizing when there is a need for adjustment and flexibility in professional function. Respect confidentiality of all parties involved in the patient/resident care process and utilize the professional skills of other team members and disciplines for improvement in the discharge plan.
Required:
Preferred:
Corewell Health cares for you:
Primary Location:
SITE - Pine Ridge Nursing & Rehab Center - 4368 S Cleveland Ave - Stevensville
Department Name:
Social Services - Pine Ridge
Employment Type:
Full time
Shift:
Day (United States of America)
Weekly Scheduled Hours:
40
Hours of Work:
8:00 a.m. to 4:30 p.m.
Days Worked:
Monday to Friday
Weekend Frequency:
Variable weekends
CURRENT COREWELL HEALTH TEAM MEMBERS Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.
Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.
Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.
An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.
You may request assistance in completing the application process by calling 616.486.7447.
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