Discharge Planner

Job Summary The Discharge Planner is a vital member of the healthcare team responsible for coordinating and facilitating the smooth transition of residents from our Skilled Nursing Facility (SNF). This position requires an organized and compassionate individual with a focus on ensuring that the discharge process is well-planned, individualized, and supportive of the resident's continued care needs. Key Responsibilities Assessment and Planning: Conduct comprehensive assessments of residents' care needs, discharge goals, and post-discharge support requirements. Collaborate with the interdisciplinary healthcare team to develop individualized discharge plans. Communication: Communicate regularly with residents, their families, and healthcare providers to discuss the discharge process, expectations, and post-discharge care plans. Serve as a liaison between our SNF, home healthcare agencies, rehabilitation centers, and other post-acute care providers. Resource Coordination: Coordinate services and resources required for post-discharge care, including home health services, medical equipment, and follow-up appointments. Collaborate with external providers to ensure a seamless transition of care. Documentation: Maintain accurate and up-to-date documentation of discharge plans, goals, and communication with residents and families. Ensure compliance with regulatory standards and facility policies. Patient Advocacy: Advocate for residents' needs and preferences in the development of discharge plans. Assist residents and families in understanding and navigating the post-discharge care process. Education and Support: Provide education to residents and their families on the management of chronic conditions, medications, and self-care strategies post-discharge. Offer emotional support and counseling as needed during the discharge planning process. Follow-up: Conduct follow-up assessments and communication after discharge to assess the success of the transition and address any issues that may arise. Collaborate with our SNF healthcare team to evaluate and improve the discharge planning process.