Transition Specialist

6 days ago

Charlottesville, Virginia, United States Commonwealth of Virginia Full time
Job Summary

We are seeking a skilled Discharge Planner to join our team at the Commonwealth of Virginia. As a key member of our healthcare team, you will play a vital role in ensuring seamless transitions from hospital to post-acute care settings.

Key Responsibilities
  • Develop and implement patient-centered discharge plans to support timely and effective transitions.
  • Collaborate with healthcare teams to identify and address social, financial, and emotional challenges related to illness, healthcare, and rehabilitation.
  • Prepare and coordinate necessary documentation and information to facilitate patient discharge or transfer.
  • Arrange for necessary equipment and transportation for patients.
  • Engage in discussions with patients and their families to ensure understanding and collaboration in the discharge planning process.
  • Document all interventions and communications in patients' medical records in accordance with departmental requirements.
Additional Responsibilities
  • Identify patients 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.
  • Review medical records, attend rounds, and respond to patients' needs. Assist case managers and/or social workers with implementing continuing care plans.
  • Under the direction of a Case Manager and/or Social Worker, assist in facilitating an appropriate discharge for patients in accordance with their medical readiness and expected needs.
  • Prepare patients and/or families for discharge by providing an explanation of the plan and what they can expect.
  • Engage other members of the care team to address patients'/families' questions and ensure adequate resolution.
  • Ensure discharge is facilitated in accordance with regulatory requirements, patient/family choice, financial resources, and third-party payer requirements.
  • Place referrals to multiple agencies reflecting the recommended level of care from the Care Management team.
  • Assist with a safe and effective handover to the next level of care by working closely with hospital staff and external agency liaisons and care navigators.
  • Complete screenings for patients regarding financial, psychosocial, physical, and medical needs to determine long-term care service supports.
  • Coordinate with outside agencies and community members to ensure continuity of services after an LTSS (UAI) screening has been completed.
  • Determine financial supports and refer patients/family members to local DSS or inpatient social workers to complete Medicaid applications or financial screenings.
  • Assess mental health needs prior to patients discharging to skilled nursing facilities to ensure appropriate services at time of discharge (understanding the need for a Level II PASRR report).
  • Document work in the medical record, meeting the requirements of the organization and department. Submit reports as required by management on things such as productivity, patient progression barriers, or other focused studies.
  • Enhance the quality of patient care by complying with policies, procedures, and the quality measures of the hospital and department. Identify and report any problems, conflicts, trends, or other potential issues to appropriate administrative staff.
Requirements
  • Bachelor's degree required, Bachelor's of Social Work preferred.
  • One year in healthcare or similar setting, hospital setting preferred.
  • None.
Physical Demands

Job requires sitting for prolonged periods, standing/traveling or use of assistive and climbing (stairs, steps). Proficient communicative, auditory and visual skills; Attention to detail, hear, speak, see, distinguish colors, read, ability to write legibly; Ability to lift/push/pull < 20lbs. May be exposed to chemicals, blood/body fluids and infectious disease.

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