Social Worker
Copley Health Systems
- Morrisville, VT
- Permanent
- Full-time
- Leads the discharge planning process which links the patient-family with the appropriate institutional or community resources post discharge and starts at time of admission or prior to planned hospitalization or surgeries.
- Utilizes Key Elements for Evidenced -Based Discharge Planning:
- Include Patient and Family as full partners in the Discharge process
- Discuss with Patients and family the five key areas to prevent problems at homes
- Describes what life at home will be like after discharge
- Review medications
- High light warning signs and problems
- Explain the plan of care including test results
- Make follow- up appointments
- Educate patient and family using plain language about the patient’s condition, the discharge process and next steps in the patients care plan.
- Assess how well doctors and nurses explain: diagnosis, condition, and next steps in the patients care to the patents and family using teach back strategies.
- Listens to and honors the patients and families goals, preferences observations and concerns.
- Case Management: Serve as a clinical resource. Contribute clinical knowledge and expertise to facilitate the attainment of the agreed upon goals of care.
- Associates Degree in Nursing
- Minimum of three (3) years relevant clinical experience including demonstrated use of discharge planning, utilization, and quality management skills. Chart reviewing-auditing, and able to extract and analyze data.
- RN License in Vermont in good standing
- Strong clinical skills, leadership, and computer skills.
- Able to establish and maintain strong working relationships.
- Self-directed, assertive problem-solving.
- Effect assessment and planning skills.
- Effective written and oral communication skills.
- Champions and builds interdisciplinary teams.