DISTINGUISHING FEATURES OF THE CLASS: The work involves providing discharge planning services to patients and their families, including pre and post discharge information, assistance and referrals. The incumbent works directly with patients and their families to assess patient needs and to direct the patient to appropriate support staff and outpatient service agencies. Work is performed under the general supervision of higher-level professional staff. Supervision is not a function of this position. Does related work as required.

TYPICAL WORK ACTIVITIES:

Interviews patients, family and friends to gather detailed information covering functional status, fiscal, legal, emotional and relevant personal/family/social strengths and weaknesses;

Assesses support network;

Collects and revises information on community health and welfare resources;

Assesses the value of additional psychological support and counseling for patient and family and makes appropriate referrals;

Assesses overall patient-family stability and makes referrals to appropriate community agencies for follow-up services;

Provides basic emotional support through understanding patient situation and giving practical guidance and information;

Evaluates and refers insurance programs to support discharge plan (e.g. referral for Medicaid application, crime victims, etc.);

Works with patient’s family and friends and enlists their help in his/her discharge planning;

Documents completion of patient/family tasks and interaction in medical chart;

Assists or arranges for post discharge care to home or facility placement;

Assists the patient, families and/or community agencies to resolve barriers to discharge or successful community living;

Assists patients in securing required appliance(s) through agencies and rentals;

Arranges specific screening, linking planning meetings with family, social agencies, home care agencies, etc. to link patient and to work out a plan of care;

Meets with patients and families to offer nursing home/rehabilitation options and transportation options; coordinates or may directly provide transportation;

Works as a member of interdisciplinary team and coordinates discharge activities with the overall team, including equipment ordering, arranging linkage and community follow-up;

Assesses overall patient-family stability and makes referral to appropriate community agencies for follow-up services;

Makes post discharge appoint in collaboration with the patient/family;

Participates in Total Quality Improvement activities.

FULL PERFORMANCE KNOWLEDGE, SKILLS, ABILITIES AND PERSONAL CHARACTERISTICS:

Good knowledge of modern principles and practices of discharge planning casework; good knowledge of discharge planning services performed in a hospital or long-term care/skilled nursing facility; good knowledge of available ECMCC and community services as it relates to patient/resident health status; working knowledge of applicable laws, rules, regulations, accreditation standards, and ECMCC policies and procedures; skill in interviewing; ability to apply discharge planning casework techniques in a hospital or long-term care/skilled nursing facility; ability to communicate effectively, both orally and in writing; ability to establish and maintain effective working relationships with a diverse constituency; ability to utilize a variety of electronic software applications; empathy; sound professional judgment; capable of performing the essential functions of the position with or without reasonable accommodation.

MINIMUM QUALIFICATIONS:

• NOTE 1: Graduation from a regionally accredited or New York State registered college or university with a Master’s Degree in Social Work, Psychology, Nursing, Human Services, Counseling or closely related field may be substituted for six (6) months of experience in health care, counseling, social work or discharge planning.

SPECIAL REQUIREMENTS:

Section 424-A of the Social Services Law requires local Social Services District to inquire whether the applicant is the subject of an indicated child abuse or maltreatment report on file with the State Central Register of Child Abuse and Maltreatment. All potential employees for this position will be requested to sign the necessary clearance form prior to being advised that they will be hired. Refusal to sign will be cause for automatic non-selection.

IN ADDITION, SPECIAL REQUIREMENTS IF ASSIGNED TO A BEHAVIORAL HEALTH INPATIENT SETTING:

Possession of Basic Life Support (BLS) Certification within thirty (30) days of appointment and maintenance throughout duration of appointment;

Completion of New York State Office of Mental Health Preventing and Managing Crisis Situations (PMCS) Training as provided by a New York State-authorized training agency within thirty (30) days of appointment and maintenance throughout duration of appointment.

NOTE 2: Verifiable part-time and/or volunteer experience will be pro-rated toward meeting full-time experience requirements.

@Approved by Erie County