Wentworth-Douglass Hospital, a subsidiary of Massachusetts General Hospital, is renowned as one of the largest acute care hospitals in the Seacoast region of New Hampshire and Southern Maine. At Wentworth-Douglass, we value people who contribute to patient-centered care that enhances community health; we recognize and reward those who share our values and transform our patients' lives. We invite you to explore opportunities, cultivate community wellness and professional growth.
The Discharge Planner RN is responsible for a designated patient caseload and works with patients and the interdisciplinary care team to facilitate care transitions.
• Asses all patients for discharge needs per CMS guidelines.
o Meet directly with patient/family to assess needs and develop an individualized plan.
o Collaborate and communicate with all members of the care team to remove any barriers to care transitions.
o Discusses cases with the attending physicians.
o Ensure and maintain discharge plan consensus with patient/family, physician and payer.
o Documents the discharge planning information in the medical record according to department standards.
o Seeks consultation from appropriate disciplines to expedite care and facilitate discharge.
• Facilitates coordination of care for patients along the healthcare continuum.
o Make all referrals for SNF, ARF, Home Services, Home IV, Enteral therapy and DME after providing patient/family with their agency options.
o Participates in multidisciplinary discharge planning rounds.
o Explores strategies to promote efficient resource utilization and timely care transitions.
o Communicates with external case managers as appropriate.
o Communicates/ collaborates with all members of the health care team, including the patient, payers, & administrators, regarding the patient's needs, plan, & response.
• Demonstrates professionalism in the completion of job functions within Coordination of Care.
o Collaborate with Social Work regarding long term care, hospice and guardianship.
o Coordinate team meetings/complex care huddles for medically complicated patients.
o Ensures plan of care remains patient focused.
o On-going collaboration with the Care Team.
o Assists medical record coders in clarification of medical clinical documentation issues.
• Demonstrates excellence in leadership skills and professional performance.
o Maintains close communication with directors regarding quality of care, risk, and infection control issues.
o Facilitates/ participates in ad hoc patient/ family conferences designed to gather information & resolve issues related to the provision of care.
o Participates in departmental and hospital committees, ad hoc committees, task forces and work groups.
o Educates health team colleagues about case management, including the role of the case manager and the needs of the case-managed population.
o Participates in educational programs as requested &/or as appropriate.
• Collects data pertinent to care management, utilization management, and performance improvement.
o Collects data related to clinical pathway variances.
o Reports adverse drug reactions appropriately.
o Reports issues related to infection control/ surveillance.
o Documents delays in transition in Midas Avoidable Denied Days entry.
• Experience Minimum Required
• 3 years of nursing experience
• Experience Preferred/Desired
• Experience in home health nursing.
• Education Minimum Required
• Education Preferred/Desired
• Bachelors Preferred; Certification in Case Management
• Special Skills Minimum Required
• Strong clinical assessment skills and knowledge of medical standards of care.
• Ability to interrelate with physicians, nurses and other hospital personnel.
• Knowledge of government, voluntary and regulatory standards, requirements and guidelines.
• Knowledge of principles related to release of information and maintenance of confidentiality of data.
• Oral and written communication skills.
• Knowledge of basic infection control practice.
• Knowledge of third party payer systems and levels of care.
• Ability to work independently.
• Strong organizational and time management skills.
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