Discharge Planner
Core
Coordinate safe hospital discharges and transitions to community or institutional settings for patients with complex medical, functional, cognitive, and psychosocial needs.
Role type
Discharge Planner (Social Work)
Builds
Safe patient transitions and continuity of care plans
Domain
Healthcare / Social Work / Gerontology
Deliverable
client delivery
Required skills
discharge planning, case coordination, community resource identification, legal/financial capacity assessment, stakeholder communication, interdisciplinary collaboration, high-risk screening, advocacy for system changes
Preferred skills
knowledge of social determinants of health, experience with aging populations, familiarity with Public Hospitals Act and Substitute Decisions Act
Technologies
None stated
Responsibilities
Formulate and implement discharge plans; identify short and long-term care goals; communicate plans to stakeholders and process referrals; educate patients/families on discharge plans and community contacts; advocate for gaps in services and system-level changes
Seniority
Mid-level, hands-on IC