Cincinnati, OH30+ days ago
Assess patients' evolving medical situation from a psychosocial framework, including functional status, goals of care, and community support needs as it relates to discharge planning • Assess family structure, dynamics, and decision-making preferences, including identification of a surrogate decision maker if needed • Assess patient/family environmental risk factors, patient/family/community support systems, age-related/developmental issues, financial barriers, health literacy, chemical dependency/mental health, Social Determinants of Health needs, and any risk of abuse/neglect/financial exploitation/intimate partner violence • Assess for risk of readmission, putting into place a coordinated plan for outpatient follow up. • Provide extensive education to patient/family in areas of insurance benefits, and capacity of community resources to meet patient needs • Participate in interdisciplinary patient care rounds, case conferences and family conferences for purpose of appropriate length of stay discharge planning.