
Discharge Planner
- Oakville, ON
- 46.004-59.637 $ par an
- Permanent
- Temps-plein
- Coordination, formulation/development, documentation, and implementation of care plan for hospital discharge and safe transition back to community or institutional setting.
- Identification of both short and long term goals to ensure/enhance continuity of care for patient/family.
- Ensure plan is communicated to all stakeholders and that appropriate referrals have been processed and received
- Ensure that patient and/or SDM understands the discharge plan and has the relevant contact information for community partners.
- Ensure efficient use of hospital and community resources
- Early identification of patients requiring complex discharge planning case management through high risk screening criteria, consultation with team members and referrals.
- Planning, review and communication of plans and time lines in partnership with the multidisciplinary team, client/SDM, family, and community agencies/facilities.
- Facilitation of safe patient discharge through: case coordination and development of appropriate discharge plan. Included but not limited to: patient/family education; referral and completion of application to community services; coordination of legal/financial capacity or SDM issues including potential PGT involvement.
- Advocate to identify gaps in services, need for individualized program consideration and system level changes required to meet changing needs of patient population.
- BScN or BSW or MSW required
- Current registration and membership in good standing with respective regulated College (OCSWSSW, ONA)
- 2-5 year clinical experience in an acute care hospital setting
- Minimum of three years, including community work and/or gerontology, discharge planning
- Current knowledge of community resources and initiative to proactively search for new resources
- Experience with legislation that governs Public Hospitals (Public Hospitals Act, Substitute Decisions Act, Consent to Treatment Act, etc.)
- Demonstrated extensive knowledge base of resources in the public and private sector, and medical and clinical language and procedures.
- Extensive knowledge of how to effectively serve an increasingly aging and diverse population with complex medical, functional, cognitive and psychosocial needs
- Comprehensive knowledge of the impact of social determinants of health on discharge planning, hospital LOS, Patient Flow and hospital system capacity
- Expert communication, collaboration, organizational and problem solving skills
- Ability to work independently as well as with an interdisciplinary team
- Demonstrated ability to set priorities
- Skilled working with a broad range of client groups and their significant supports
- Satisfactory employment and attendance record