Discharge Planner at Halton Healthcare — NeverHard

Job Description The Social Work and Discharge Planning team consists of staff that provide scope of practice social work and discharge planning for all four sites of Halton Healthcare (including the Burlington Satellite Dialysis Program). The successful candidate will work within a fast-paced environment as a collaborative team member of an interdisciplinary team, supporting in-patient units to address high priority discharge barriers. Using critical thinking and working with the interdisciplinary team, the Discharge Planner collaboratively formulates, facilitates and coordinates discharge plans focused on the needs and goals of the patient and their family system. The Discharge planner understands the Flow and Capacity challenges of a hospital system and works to achieve that the patients are in the right place, at the right time, receiving the right care. Coordination, formulation/development, documentation, and implementation of care plan for hospital discharge and safe transition back to community or institutional setting. Identification of both short and long term goals to ensure/enhance continuity of care for patient/family. Ensure plan is communicated to all stakeholders and that appropriate referrals have been processed and received Ensure that patient and/or SDM understands the discharge plan and has the relevant contact information for community partners. Ensure efficient use of hospital and community resources Early identification of patients requiring complex discharge planning case management through high risk screening criteria, consultation with team members and referrals. Planning, review and communication of plans and time lines in partnership with the multidisciplinary team, client/SDM, family, and community agencies/facilities. Facilitation of safe patient discharge through: case coordination and development of appropriate discharge plan. Included but not limited to: patient/family education; referral and completion of application to community services; coordination of legal/financial capacity or SDM issues including potential PGT involvement. Advocate to identify gaps in services, need for individualized program consideration and system level changes required to meet changing needs of patient population.