Discharge Planning Associate-Clinical Care Coordination (Community) - University of Pittsburgh Medical Center : Job Details

In conjunction with the Discharge Planning team, the Associate coordinates the appropriate support services and resources throughout UPMC to facilitate effective discharge plans that achieve optimal satisfaction, clinical, and financial outcomes along the defined continuum of care. Responsibilities: Identify clinical, psychosocial, historical, financial, cultural, and spiritual needs that guide the planning process with the patient to attain optimal outcomes. Take patient/family/caregiver level of health literacy into consideration. Evaluate patient/family/caregiver level of understanding and engagement with the progress toward goals and incorporate findings into the plan of care. Balances resources with patient preferences and goals of care. Evaluate the potential impact of social determinants of health that may elevate the risk of a poor transition. Complete detailed assessment on every patient in order to establish understanding of medical and social factors, determine patient's cap...Clinical, Associate, Planning, Caregiver, Healthcare, Patient, Health