Within the inpatient setting to assess and address patient and family needs related to effective and efficient movement through the hospital system and beyond.
1. Perform initial screening on all patients within one day of patient being available to the case manager. Begin discharge planning process on patients deemed to be high risk through the screening process.
2. Ensure that the patient transitions through their stay without barriers or delays in care delivery and discharges to appropriate level of care.
3. Work closely with interdisciplinary team to proactively identify discharge needs.
4. Coordinate discharges to the next level of care, working to facilitate safe transitions with the goal of preventing avoidable readmissions.

Expert Caring

+ Per department documentation standards:
+ Completes initial screening, and comprehensive assessment as indicated
+ Identifies discharge goals with patient/family early in hospital stay
+ Provides and do...