Ability to assess, diagnose and plan for interventions relatedt o patient and family needs and behaviors. Integrates assessment using information related to cultural, clinical, ethnic, age and other factors into plan of care in order to implement transition plans and treatments. Acts as active team member in the discharge planning process and primary responsibility for identifying complicating social and financial factors and barriers to appropriate discharge. Assures that patient is referred to appropriate social and financial resources post discharge in order to transition patient efficiently and achieve the desired outcome. Refers patients/families and care givers to appropriate resources regarding abuse/neglect/domestic violence, alcohol and substance abuse. Performs appropriate clinical interventions related to grief counseling, bereavement, adjustment, crisis intervention in order to support the process of transition planning. Participates and develops inpatient and community programs that benefit patient, families and staff. Implements support groups for specified disease processes to assist community outreach and development. Performs follow up service as needed to measure clinical outcomes.
Internal Number: 52610BR
About Inova Health System
Inova is a global leader in personalized health, which leverages precision medicine to predict, prevent and treat disease, enabling individuals to live longer, healthier lives. At Inova, we serve more than two million people each year from throughout the Washington, DC, metro area and beyond. Inova's mission is to improve the health of the diverse community it serves through excellence in patient care, education and research. At Inova, more than 16,000 employees demonstrate their commitment every day to providing the community with expert, world-class, compassionate patient care.