Discharge Planner

**Position Summary**:

- For more than 90 years St. Mary’s General Hospital has fostered a culture of innovation, compassion and respect. With this vision, St. Mary’s has developed an environment that inspires people to perform to the best of their ability. Passion, excellence and innovation are deeply embedded in all we do. St. Mary’s uses these principles to foster a healthy, supportive work environment that cares for the well-being of our community - mind, body and spirit. When you join St. Mary’s, your contribution will make a positive impact to the quality of life for patients and families. In addition, you will join a team dedicated to making St. Mary’s the safest and most effective hospital in Canada. _

This position is responsible for collaborating with patients and their families to develop quality, timely and cost effective individual plans for service provision, based on patient needs, utilizing a multi-disciplinary approach to achieve optimal health outcomes.

The purpose of this position is to assist patients in achieving their highest level of functioning and independence, consistent with their values, priorities, capacities and preference of care. The Discharge will determine eligibility for services in accordance with applicable policies and procedures.

The Discharge planner will provide comprehensive clinical services to patients and families.This role involves crisis intervention, emotional support, consultation, counseling, completion of referrals and connecting patients to appropriate community services. The Discharge Planner takes a lead in working with patients and families, providing patient education and counseling, and making referrals support services in an effort to address patients’ goals

**Patient Care**
- Refer clients/patients to ongoing community based services where required
- Participation in patient care planning with a focus on discharge planning rounds, patient care conferences, team and family meetings.
- Develops appropriate treatment modalities related to specific diagnostic populations (ie:

- Embody the mission, vision and values of the organization and enhance the patient experience, enhance provider/staff experience, improving value and improving populations health) to support continuous quality improvement in daily work
- **Exemplify, embrace and intentionally promote an inclusive work environment where all are meant to feel they belong**:

- **Continually demonstrate a commitment to create a positive culture of equity, inclusion, diversity and anti-racism**:

- **Conducts patient assessments/eligibility within the hospital to determine the patients eligibility for the appropriate services and programs**:

- **Develops appropriate service planning and engages the patient/family to meet the patient’s needs using negotiating, problem-solving and decision making skills**:

- **Designs, in consultation with the patient/caregiver, a multi-disciplinary service plan to meet identified needs and goals**:

- **Provides for extenuating service planning as appropriate**:

- **Monitors the service plan, modifying it in response to changing needs**:

- **Develops collaborative working relationships with other Hospital and Community staff and enhances existing working relationships with a broad range of community agencies, effectively linking individual patients and families with appropriate resources**:

- **Works with patient’s informal and formal supports, along with community partners to support the patient to self-manage their disease with a goal to improve or maintain quality of life and to reduce dependence on acute care resources**:

- **As assigned, works collaboratively with primary care partners to support patient goals and manage health care needs**:

- **Promotes and plans for the early discharge of appropriate patients from hospital setting through collaboration with patient, family and members of the healthcare team ensuring the discharge plan and hospital needs are documented**:

- **Provides information throughout the health care trajectory, reviews assessments, makes referral and may counsel patients in the area of community services**:

- **Collaborates with clinical leaders in the development of system-wide diagnosis related pathway development**:

- **Informs patients and supports independence in the management of the patient’s health care needs throughout the illness trajectory**:

- **Provides consultation within multidisciplinary team concerning social/emotional factors, related to specific diagnoses.**:

- **Provides crisis intervention and emotional support to patients and families on bio-psychosocial issues.**:

- **Advocate for needs of patients/family both in hospital and follow-up in the community.**:

- **Ensures cost effective use of services and supplies by reviewing and interpreting utilization and service provider reports, coordinating care reviews, multi-disciplinary patient conferences and reassessment visits**:

- **Co