Discharge Planner

In support of patient progression practice, provides patient/family focused interventions to support timely discharge outcomes. Facilitates the pace of the case for real time completion of concrete interventions identified in the discharge plan. Using a variety of modalities carries out discharge plan recommendations for the alleviation or resolution of social financial and emotional problems related to illness, healthcare and rehabilitation allowing a timely transition of a patient from the hospital to the most appropriate next level of care.

Activities include such things as preparing information to facilitate a patient’s discharge/transfer, arranging equipment and transportation, and discussing plans with the patient and family. Documents her/his work in the patients’ medical record per department requirements.

• Identifies patient and/or families requiring coordination of continuing care or community support through collaboration with case managers, social workers and other members of the care team.  Reviews medical records, attends rounds, and responds to patients needs.  Assists the case manager and/or social worker with implementing continuing care plans.  Applies knowledge based on professional experience.
• Under the direction of a Case Manager and/or Social Worker assists in the facilitation of an appropriate discharge for her/his patients in accordance with the patient’s medical readiness and expected needs.  Assists in coordinating a patients discharge/transition to settings such as skilled nursing homes, home with home health, patients with medical equipment, etc.
• Prepares the patient and/or family for discharge by providing an explanation of the plan and what the patient/family can expect.
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