Social Worker - Discharge Planning Coordinator - Toledo Hospital - Care Navigation

Overview POSITION SUMMARY: The Social Worker/Discharge Planning Coordinator intervenes with patients who are psychosocially complex, have Social Determinants of Health (SDOH) needs, and/or require assistance with transitions of care or discharge planning. The role offers supportive intervention (e.g., trauma, terminal diagnosis, mental health) to patients and caregivers and coordinates the development of discharge plans for high-risk/complex patient populations. They may self-refer or receive referrals from interdisciplinary team members and collaborate with the care team to escalate appropriately to ensure patients receive exceptional care and avoid unnecessary delays in care or discharge. Responsibilities Psychosocial Assessment and Interventions: assess and address psychosocial risk factors for patients and caregivers, including coping, support systems, and impact of illness. Provide intervention related to emotional, social, and financial consequences of illness; connect to caregiver and community resources. Offer information and interventions related to treatment decisions and end-of-life issues; advocate for patient and caregiver empowerment. Document findings in the EMR and develop therapeutic relationships to facilitate discharge planning and collect necessary psychosocial and SDOH information. Identify patients at risk for readmission and those needing intensive discharge planning using admission data, EMR analytics, and proactive case finding. Assess inpatients for self-care ability and risk of post-discharge adverse health outcomes without intensive discharge planning. Complex Discharge Planning: participate in discharge planning activities for psychosocially complex patients and ensure timely discharge with appropriate linkage to post-discharge care providers. Support discharge planning for various scenarios (e.g., new facility placements, new dialysis patients, hospice, housing instability, CAM, caregiver dynamics, guardianship, financial/indigent concerns, safety concerns, and other community resources). Educate patients, caregivers, and physicians regarding post-acute options and respect patient choice. Coordinate with the interdisciplinary team, post-acute care providers, and community resources to ensure suitable care settings align with patient goals and preferences. Communicate necessary medical information to facilities or services for follow-up or ancillary care. Facilitate patient/caregiver conferences regarding acute plans of care and/or discharge; ensure plan consistency across settings. Ask for escalation through acceleration channels to address discharge delays and care progression concerns as appropriate. Participate in Daily Transition Rounds (DTRs) and contribute to discharge planning discussions. Qualifications Required Qualifications Education: BSW or higher degree; limited licensed Social Worker considered on a case-by-case basis. Skills: Knowledge of regulations, community resources, and ability to function in a critical care environment. Strong written and verbal communication, prioritization, negotiation, critical thinking, problem-solving, and customer service skills. Ability to work with diverse populations and adapt to change. Proficiency with Outlook and EMR; understanding of pre- and post-acute care resources. License: Licensed Social Worker Certification: N/A Preferred Qualifications Education: MSW Skills: Experience in patient advocacy, care management, and knowledge of hospital and community resources. Years of Experience: Prior case management or discharge planning experience preferred. License: N/A Certification: CCM, ACM, or similar care management certification preferred. Working Conditions Personal Protective Equipment: N/A Physical Demands: Ability to stand for long periods and work rapidly for extended periods. Organizational information: ProMedica is a mission-based, not-for-profit integrated healthcare organization headquartered in Toledo, Ohio. For more information, please visit EEO Statement: Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. If you require an accommodation to apply, please contact View email address on click.appcast.io Equal Opportunity Employer/Drug-Free Workplace Requisition ID: 94884 #J-18808-Ljbffr ProMedica Health System