Uses and documents levels of care criteria for all assigned patients throughout the patient's hospitalization.
Evaluates each patient for appropriate level of care.
Ensures hospital reimbursement for services.
In collaboration with the interdisciplinary team (IDT), creates and implements an appropriate plan of care for each patient.
Identifies obstacles to patient care goals and throughput; intervenes to overcome or eliminate these.
Demonstrates caring and involved behaviors to patient/family members and is an active and engaged advocate to achieve positive outcomes.
Negotiates with payers and healthcare agencies for services; identifies internal and/or external resources and refers appropriately to meet patient needs.
Identifies patients who may benefit from Palliative Care and is an active member of the Palliative Care Team for assigned patients.
Educates patients and families about payer issues and coverage including appropriate governmental rules and regulations.
Discharge Planning/Psycho-social Services
Performs initial discharge planning assessment. In conjunction with other members of the IDT and the patient and /or patient representative and family develops a discharge plan. Continuously monitors appropriateness of plan and ensures timely implementation.
Ensures patient, family, members of the IDT and post-discharges provider are educated about the discharge plan.
Ensures continuity of patient care between hospital and post discharge providers.
Collaborates with Department Social Workers regarding patient clinical condition, discharge planning and psychosocial issues. Refers complicated discharge planning arrangements, guardianship and conservator questions and as appropriate psychosocial issues to Social Workers.
Internal Number: 560512
About SCL Health
MissionWe reveal and foster God's healing love by improving the health of the people and communities we serve, especially those who are poor and vulnerable.VisionInspired by our faith, •We will be distinguished as the premier person-centered health system and trusted partner. •We will share accountability with clinicians and other stakeholders to coordinate care across all settings and improve access, quality, health outcomes, and affordability. •We will grow as community-based health networks to serve more people in partnerships with others who share our vision and values. ValuesCaring Spirit - We honor the sacred dignity of each person.Excellence - We set and surpass high standards.Good Humor - We create joyful and welcoming environments.Integrity - We do the right thing with openness and pride.Safety - We deliver care that seeks to eliminate all harm for patients and associates. Stewardship - We are accountable for the resources entrusted to us.