Hospital Discharge Planner (NADMIN 11/23)

Full Time (Non-Union)

Department: Nursing

Reports to: Patient Care Manager

Job Summary:

The hospital Discharge Planner is responsible for assessing the psychosocial needs of the patient and family to develop, communicate, and implement an effective and comprehensive plan for psychosocial interventions and complex discharges.

• A degree from an accredited undergraduate social work program or equivalent Health Care Degree.
• Active registration with the Ontario College of Social Workers and Social Service Workers or equivalent Health Care Experience required.
• Demonstrated knowledge and practical experience in working with community organizations and resources.
• Demonstrated knowledge and practical experience in working with an Interdisciplinary team.
• Demonstrated knowledge and practical experience with patient flow including the inpatient unit and emergency department.
• Excellent interpersonal and leadership skills.
• Excellent communication skills both written and verbal.
• Ability to work well independently.
• Knowledge and sensitivity to First Nations language and culture an asset.
• Experience working in a case management model of care an asset.

• Under the Discharge Team Lead, assist to facilitate patient discharge within the organization.
• Facilitates case management and discharge planning for the hospital, specifically the ALC group.
• Lead the ALC care team staff to ensure the ALC patient care is in compliance with the individual care plans.
• Ensure each ALC patient has an individualized care plan.
• Complete RAI assessments on the CCC patients and assist with bed movement and patient transfer either to LTC or other facilities.
• Works cooperatively and collaboratively with the Rehabilitation Team to provide services that are individualized and tailored to address the client and family needs and preferences through referral and collaborative strategies.
• Work with families and community agencies to navigate and improve transition between services for all patients.
• Develop supportive programming to meet the needs of the patients and families serviced. (Palliative Care, Cognitive supports).
• Facilitate professional development for providers in the areas of social support, quality of life and end of life care.
• Perform post discharge follow up communication to evaluate services provided
• Must adhere to organizational policies and procedures concerning cleaning, hand hygiene and the use of Personal Protective Equipment in support of Infection Control measures and attend training when necessary.