St. Luke's Rehabilitation Hospital, a joint venture between St. Luke's Hospital and Kindred Healthcare is located three miles west of St. Luke's Hospital on the campus of Surrey Place. Our 35-bed, nearly 30,000 square-foot rehab hospital providing intensive inpatient rehabilitation programs and services to patients with severe illnesses and injuries, like stroke, traumatic brain injury, neurological disorders, amputation, spinal cord injury and other debilitating conditions.
This position will work under the direction of the DCM and assumes responsibility and accountability for the coordination and implementation of case management strategies pursuant to the Case Management Plan. Plans and coordinates care of the patient from pre-hospitalization through discharge. Coordinates the discharge planning function in conjunction with the social worker, admissions coordinator and assists with the screening, investigation and problem solving as needed.
Meets with patient upon admission to discuss rehabilitation process and role of manager/case manager in individual's program.
Conducts and documents initial patient assessment within 48 hours to include psychosocial, family and disposition status; determines tentative, initial discharge plans in conjunction with patient and family goals. Appropriately modifies approach to the patient based upon patient's age and developmental level.
Involves the patient/family in the development of the plan of care by obtaining their goals for rehabilitation.
Reviews goals with patient's family and third party payor. Maintains accurate up-to-date documentation in the medical records of patient and family contacts, communications with payors and other services performed on behalf of patient and family.
Leads/Co-Leads team conferences. Documents in the medical record a summary of the team conference. Serves as the primary family contact for the treatment team, communicating within 24 hours of the care conference. Also updates external case manager and/or payor source regarding progress, plan and patient's future needs (within 24 hours of staffing or as requested by payor sources).
Ensures the scheduling of family conferences, family participation in therapy and provides pertinent information to appropriate team members. Documents in the medical record a summary of the family conference.
* Coordinates completion of discharge plans by assisting with arrangements for family education, equipment, and services as appropriate for patient discharge level of care.
* Calls patient or family within established time frame post-discharge to ensure planned discharge recommendations are occurring and to assess if additional services are needed.
* Participates in monitoring, analyzing and utilizing program evaluation data to promote quality of care, increase marketing activity and to position hospital for success.
* Responsible for ensuring that all necessary communication between referral sources and the facilities occurs in a timely manner.
The successful candidate must have a bachelor's degree in Social Work, Psychology, Sociology, or Registered/Licensed Nurse licensure in the state of Missouri; Master's degree preferred. Minimum of 2 years social work or case management experience required; acute/rehabilitation hospital experience preferred.
Job : Social Services Primary Location : MO-Chesterfield-St. Luke's Rehab Hospital Organization : 4837 - St. Luke's Rehab Hospital Shift : Day