Discharge Planner

The Social Work and Discharge Planning team consists of staff that provide scope of practice social work and discharge planning for all sites of Halton Healthcare.
The successful candidate will work within a fast-paced environment as a collaborative team member of an interdisciplinary team, supporting in-patient units to address high priority discharge barriers. Using critical thinking and working with the interdisciplinary team, the Discharge Planner collaboratively formulates, facilitates and coordinates discharge plans focused on the needs and goals of the patient and their family system. The Discharge planner understands the Flow and Capacity challenges of a hospital system and works to achieve that the patients are in the right place, at the right time, receiving the right care.
Coordination, formulation/development, documentation, and implementation of care plan for hospital discharge and safe transition back to community or institutional setting.
Identification of both short and long term goals to ensure/enhance continuity of care for patient/family.
Ensure plan is communicated to all stakeholders and that appropriate referrals have been processed and received
Ensure that patient and/or SDM understands the discharge plan and has the relevant contact information for community partners.
Ensure efficient use of hospital and community resources
Early identification of patients requiring complex discharge planning case management through high risk screening criteria, consultation with team members and referrals.
Planning, review and communication of plans and time lines in partnership with the multidisciplinary team, client/SDM, family, and community agencies/facilities.
Facilitation of safe patient discharge through: case coordination and development of appropriate discharge plan. Included but not limited to: patient/family education; referral and completion of application to community services; coordination of legal/financial capacity or SDM issues including potential PGT involvement.
Advocate to identify gaps in services, need for individualized program consideration and system level changes required to meet changing needs of patient population.
Halton Healthcare endeavors to hire individuals who are competent in their chosen profession and who exemplify our mission, vision and values of accountability, respect and compassion which guide our individual behaviours and attitudes.
BScN or BSW or MSW required
Current registration and membership in good standing with respective regulated College (OCSWSSW, ONA)
2-5 year clinical experience in an acute care hospital setting
Minimum of three years, including community work and/or gerontology, discharge planning
Current knowledge of community resources and initiative to proactively search for new resources
Experience with legislation that governs Public Hospitals (Public Hospitals Act, Substitute Decisions Act, Consent to Treatment Act, etc.)
Demonstrated extensive knowledge base of resources in the public and private sector, and medical and clinical language and procedures.
Extensive knowledge of how to effectively serve an increasingly aging and diverse population with complex medical, functional, cognitive and psychosocial needs
Comprehensive knowledge of the impact of social determinants of health on discharge planning, hospital LOS, Patient Flow and hospital system capacity
Expert communication, collaboration, organizational and problem solving skills
Ability to work independently as well as with an interdisciplinary team
Demonstrated ability to set priorities
Skilled working with a broad range of client groups and their significant supports
Satisfactory employment and attendance record

Employment type
Full-time

Work arrangement
No