Discharge Planner

The Social Work, Discharge Planning and Patient Flow team consists of staff that provide scope of practice social work and discharge planning for all four sites of Halton Healthcare (including the Burlington Satellite Dialysis Program), and Patient Flow to the Oakville and Milton sites.

The successful candidate will work within a fast-paced environment as a member of an interdisciplinary team. Using critical thinking and working in collaboration with the interdisciplinary team, the discharge planner 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

Hours: Monday - Sunday - Days - 8 hour shifts (Hours subject to change based on operational requirements)

Salary: $ $57.90 per hour

Date Posted: June 11, 2024

Internal applications due by: June 18, 2024

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Halton Healthcare is an equal opportunity employer who is committed to integrating diversity, equity and inclusion throughout our operations, policies and culture. If you are passionate about what you do, motivated by a job well done, and as committed to excellence, quality and patient satisfaction as we are, we'd like to hear from you. Please attach your current resume directly to this posting.

We thank all those who apply but only those individuals selected for further consideration will be contacted.

Halton Healthcare is committed to providing accommodations for applicants with disabilities. In accordance with the Accessibility for Ontarians with Disabilities Act and the Ontario Human Rights Code, Halton Healthcare will provide accommodations throughout the recruitment and selection process. If you require an accommodation, we will work with you to meet your accommodation needs to ensure your equal participation.

All new hires must be fully compliant with our Vaccination Policy as a condition of employment with Halton Healthcare. Successful applicants will be required to provide proof of vaccination or proof of a documented medical exemption as part of the hiring process.

All personal information is collected under the authority of the Freedom of Information and Protection of Privacy Act.