Peterborough, NH30+ days ago
Develops and coordinates inpatient discharge plans for patients who are considered at risk for adverse outcomes (i.e., such as readmission, medication error, falls, etc.) as determined by the interdisciplinary care team and in collaboration with the RN UR/ Case Manager and other members of the care team, such as physicians, nurses, pharmacy, therapy, Primary Care social workers, etc. The SW Case Manager is responsible for working with patients, families and interdisciplinary care team members with the overall goal of developing transitional care plans that are patient-centered and are formulated in a manner that respects patients’ individual needs, values and goals and are developed in alignment with available resources.