Completes social service assessment upon admission while immediately focusing on discharge planning and follow-up care. Individual, group and family therapy, education, and plan of care will be ongoing throughout the continuum of care. This position participates in a multidisciplinary palliative care team. Completes and updates medical records pertaining to case management and authorizations.
Drives the psychosocial assessment in identified time frame and immediately begins discharge planning upon admission.
Directs daily individual, group and family therapy according to the unit/program schedule.
Coordinates discharge planning arrangements to skilled nursing, residential and rehabilitation facilities, while completing all required documentation.
Updates relevant patient information within medical record on a daily basis to assist treatment team in coordinating care plan.
Joins with other disciplines, reviews comprehensive patient/ family treatment plan.
Collaborates with physicians and other health care professional regarding patient plan of care and intermediate care goals within proposed time line.
Reviews and evaluates discharge planning on all clients while scheduling follow-up appointments.
Interview patient / family members, obtain a complete initial social history.
Performs all other duties according to entity policies/procedures as assigned.
You’ve known us as many names throughout St. Louis, and now, we’re bringing our hospitals, doctors, home care and other services together under one name – SSM Health. With seven hospitals, 350+ physicians, more than 40 physician locations and 12,000 employees, we are part of something bigger and better. We’re connected to a wealth of resources, expertise and advance technology to help you, your fa...mily and our community live long, healthy lives.
We’ve grown and changed a lot over our 143-year history. Our name may be changing but our mission remains the same