Headquartered in Wilmington, Delaware, ChristianaCare is one of the country's most dynamic health care organizations, centered on improving health outcomes, making high-quality care more accessible and lowering health care costs. ChristianaCare includes an extensive network of outpatient services, home health care, urgent care centers, three hospitals (1,299 beds), a free-standing emergency department, a Level I trauma center and a Level III neonatal intensive care unit, a comprehensive stroke center and regional centers of excellence in heart and vascular care, cancer care and women's health.

ChristianaCare Offers

• Full Medical, Dental, Vision, Life Insurance, etc.
• Two retirement planning offerings, including 403(b) with company contributions
• Generous paid time off with annual roll-over and opportunities to cash out
• 12 week paid parental leave
• Tuition assistance
• Incredible Work/Life benefits including annual membership to care.com, access to backup care services for dependents through Care@Work, retirement planning services, financial coaching, fitness and wellness reimbursement, and great discounts through several vendors for hotels, rental cars, theme parks, shows, sporting events, movie tickets and much more.

PRIMARY FUNCTION:

To assist patients and families to identify social, emotional, and environmental needs and to connect them with available resources/ services through the provision of a full spectrum of discharge planning and social work services.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

Works with the patient, family, and other members of the health care team to formulate a discharge plan that provides the patient services in the appropriate post-acute care setting. Gathers and assesses information regarding the patient's physical needs, mental status, family support system, financial resources, and available community and governmental resources. Employs assessment to develop a comprehensive case management plan that will address the patient's goals of care and identified needs for discharge planning. As part of the discharge plan development process, collaborates with other healthcare professionals in multi-disciplinary meetings and patient rounds. Receives updates and guidance regarding Utilization Management from appropriate UM staff to assist with length of stay coordination.

Determines specific objectives, goals, and measures that are designed to meet the patients' needs that have been identified through assessment. The plan will be action-oriented and time-specific including collaboration with utilization management to manage length of stay. Maintains contact with the patient's third party payors to ensure the most cost-effective plan of care is being carried out and appropriate in network providers are being utilized.

Provides information about resources and options available in the community and coordinates service delivery. Interprets patient/family needs and provides information concerning the availability and limitations of resources. Educates and addresses concerns with service delivery including service gaps and access issues. Implements discharge plan through service referral and coordination activities. The Social Worker always assures that the patient is given the choice in regard to post-acute agencies and services.

Screens high-risk patients and consults attending physicians regarding potential discharge planning problems identified as a result of this process. Interviews and assesses referred and high-risk patients to determine the need and desire for social work services.