Discharge Planning Associate, Emergency Room

About the Role

The Emergency Room Discharge Planning Associate plays a vital role in coordinating patient care and facilitating safe, efficient transitions throughout the continuum of care. This individual serves as a key resource for patients, families, providers, and the interdisciplinary care team within the Emergency Department.

Schedule & Work Environment

• Primarily scheduled for day shift (7:00 AM - 7:00 PM).
• Candidates must be available to work night shift (7:00 PM - 7:00 AM) as needed to meet department staffing needs.
• Weekend and holiday coverage is required.
• The Emergency Department is a fast-paced, high-acuity environment.
• Successful candidates must be comfortable working in crisis situations, including caring for patients and families experiencing traumatic events, medical emergencies, and behavioral health crises.
• The ability to remain calm under pressure, adapt to changing priorities, and effectively coordinate complex patient needs is essential.

Key Responsibilities

• Identify clinical, psychosocial, historical, financial, cultural, and spiritual needs that guide the planning process with the patient to attain optimal outcomes.
• Take patient/family/caregiver level of health literacy into consideration.
• Evaluate patient/family/caregiver level of understanding and engagement with the progress toward goals and incorporate 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 assessment on every patient to establish understanding of medical and social factors, determine patient's capacity for self-care, identify support systems, outline barriers to discharge, and determine the likelihood of requiring post-hospital services and the availability of such services.
• Continually reassess discharge plan for factors that may affect continuing care needs or the appropriateness of the discharge plan.
• Facilitate teams to develop and execute safe and efficient discharges.
• Maintain knowledge about area resources and their capabilities and capacities as well as various types of service providers available.
• Ensure appropriate arrangements for post-hospital care are made before discharge and work to avoid unnecessary delays.
• Integrate patients' goals, the health care team's assessment, risks, and available resources in order to develop and coordinate a successful transition plan.
• Engage in clear communication with the patient/member/caregivers as well as 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 and monitor/revise and respond to the progression of discharge milestones.
• Serve as a contact between hospitals and post-hospital care facilities as well as the physicians who provide care in either or both of these settings.
• Recognize and demonstrate shared accountability in the development of a discharge plan with the patient/member/caregiver as well as with 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 service access and for the protection of the patient's health, well-being, safety, and rights.
• Manage cost of care with the benefits of 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.
• Coordinate patient transfers to higher levels of care, facilitate placement in behavioral health facilities, assist families during critical events, and support trauma patients during stabilization and transition planning.
• Connect patients with community resources and support services necessary to ensure safe and appropriate discharge.
• Coordinate support services and resources across UPMC to facilitate effective discharge plans.

Requirements & Tech Stack

• Proficient computer skills.

Qualifications

• 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 (unless a Registered Nurse).
• Excellent communication skills required.
• Must be skilled in planning/organization, follow-up/control, problem-solving, self-development orientation, and organizational behaviors/competencies.
• Must possess the ability to apply principles of logic and critical thinking to a wide range of problems and to deal with a variety of abstract and concrete variables.
• Comfortable working both independently and as a team member.
• Prior case management or discharge planning experience is strongly preferred.
• Clinical/patient-facing experience preferred.

Licensure, Certifications, and Clearances

• Registered Nurses employed in this position are required to maintain active RN license.
• Act 34.