Discharge Planning Associate

About the Role

UPMC Chautauqua is seeking a Discharge Planning Associate to join their Clinical Care Coordination and Discharge Planning department. This is a full-time, day shift position.

Key Responsibilities

• Identify clinical, psychosocial, historical, financial, cultural, and spiritual needs to guide the patient's planning process for optimal outcomes.
• Evaluate patient/family/caregiver level of health literacy, understanding, and engagement with progress toward goals, incorporating findings into the plan of care.
• Balance resources with patient preferences and goals of care.
• Evaluate the potential impact of social determinants of health that may elevate the risk of a poor transition.
• Complete detailed assessments to understand medical and social factors, determine capacity for self-care, identify support systems, outline discharge barriers, and determine the likelihood and availability of post-hospital services.
• Continually reassess the discharge plan for factors affecting continuing care needs or the appropriateness of the plan.
• Facilitate teams to develop and execute safe and efficient discharges.
• Maintain knowledge of area resources, their capabilities and capacities, and various available service providers.
• Ensure appropriate arrangements for post-hospital care are made before discharge and work to avoid unnecessary delays.
• Integrate patients' goals, health care team's assessment, risks, and available resources to develop and coordinate a successful transition plan.
• Engage in clear communication with the patient/member/caregivers and the interdisciplinary care team to develop discharge plans.
• Serve as a liaison between the patient and the care team.
• Actively collaborate with the attending practitioner, caregivers, and other members of the multidisciplinary team to coordinate an individualized plan of care.
• Incorporate discipline-specific recommendations, test results, and outstanding orders into the discharge plan.
• Monitor, revise, and respond to the progression of discharge milestones.
• Serve as a contact between hospitals, post-hospital care facilities, and physicians providing care in these settings.
• Demonstrate shared accountability in the development of a discharge plan with the patient/member/caregiver and team members to ensure optimal outcomes.
• Align practice with the mission, vision, and values of the organization.
• Adhere to ethical standards and codes of conduct of applicable professional organizations and UPMC.
• Maintain clinical knowledge of and ensure compliance with regulatory requirements.
• Advocate on behalf of patient/family/caregivers for services access and for the protection of the patient's health, well-being, safety, and rights.
• Manage cost of care with patient safety, clinical quality, risk, and patient satisfaction to provide recommendations and decisions that ensure optimal outcomes.
• Embrace and incorporate innovation and technology to improve collaboration and patient outcomes.
• Document care in the patient medical chart.
• Provide staff orientation and mentoring as appropriate.

Requirements & Tech Stack

• Diploma or Associate's Degree in Nursing OR Bachelor's degree in social work or another health or human services field that promotes the physical, psychosocial, and/or vocational well-being of those being served.
• No license required for the role itself.
• Registered Nurses employed in this position are required to maintain active RN license.
• New York Mandated Reporter Training – Due within 90 days of hire or transfer.
• NY Mandated Reporter Training
• NYS Staff Exclusion List (NYSEL)

Qualifications

• Excellent communication skills required.
• Skilled in planning/organization, follow up/control, problem solving, self-development orientation, and organizational behaviors/competencies.
• Ability to apply principles of logic and critical thinking to a wide range of problems.
• Ability to deal with a variety of abstract and concrete variables.
• Comfortable working both independently and as a team member.
• Proficient computer skills.
• Clinical/patient-facing experience preferred.
• No experience in discharge planning/care coordination required.