Duke University Hospital is consistently rated as one of the best in the United States and is known around the world for its outstanding care and groundbreaking research. Duke University Hospital has 1,048 licensed inpatient beds and offers comprehensive diagnostic and therapeutic facilities, including a regional emergency/trauma center; a major surgery suite containing 65 operating rooms; an endo-surgery center; a separate hospital outpatient surgical department with nine operating rooms and an extensive diagnostic and interventional radiology area. For 2021-2022, U.S. News and World Report ranked Duke University Hospital nationally in 11 adult specialties: cancer, cardiology & heart surgery, diabetes & endocrinology, ear, nose & throat, gastroenterology & GI surgery, gynecology, neurology & neurosurgery, ophthalmology, orthopedics, pulmonology & lung surgery, and urology. Duke University Hospital is also ranked first in North Carolina and first in the Raleigh-Durham area.

In addition to its hospitals, Duke Health has an extensive, geographically dispersed network of outpatient facilities that include primary care offices, urgent care centers, multi-specialty clinics and outpatient surgery centers.

Occ Summary

Manage a designated caseload to coordinate and complete timely assessment, planning, implementation and evaluation of discharge plans and care transitions across the continuum of care. Ensure optimum utilization of the patient's and the Health System's resources and perform these duties within the requirements of CMS and other external review agencies.

Work Performed

Monitor daily census and assignment to assure all patients are assessed for case management needs including care coordination/transition and discharge planning, consultations, advocacy, education. Maintain effective communication with health care team members related to assessment findings, discharge planning needs and provider orders needed to arrange Homecare, Durable Medical Equipment, Transportation, Skilled Nursing or Acute Rehab Facility placement, Substance Abuse Treatment and outpatient follow-up. Maintain working knowledge of specific benefits and reimbursement guidelines, thedischarge planning process and applicable federal, state and local regulations. Provide education and guidance on these topics to providers, patients and families as needed. Work with Utilization Management partners to provide information and feedback that will enhance negotiations and denial prevention with payers. Maintain timely documentation of assessment findings, discharge arrangements and actions taken according to departmental guidelines; prepare reports and maintain records as requested and/or required. Monitor daily census and assignment to assure all patients are assessed for case management needs including care coordination/transition and discharge planning, consultations, advocacy, education. Maintain effective communication with health care team members related to assessment findings, discharge planning needs and provider orders needed to arrange Homecare, Durable Medical Equipment, Transportation, Skilled Nursing or Acute Rehab Facility placement, Substance Abuse Treatment and outpatient follow-up. Maintain working knowledge of specific benefits and reimbursement guidelines, the discharge planning process and applicable federal, state and local regulations. Provide education and guidance on these topics to providers, patients and families as needed. Work with Utilization Management partners to provide information and feedback that will enhance negotiations and denial prevention with payers. Maintain timely documentation of assessment findings, discharge arrangements and actions taken according to departmental guidelines; prepare reports and maintain records as requested and/or required. Inpatient Job Responsibilities/Activities Complete initial assessment within 72 hours to identify psychosocial strengths, weaknesses, community living supports present and needed. Contact with patient primary support systems to gather information regarding dynamics and needs of support system. Conduct support system/family therapy to allow patient/support to practice skills needed to support community living and/or assist in development of functional patterns of interactions. Conduct group sessions for patients focused on skill building/interactional skills. Assist patient in development of safety plan to promote positive coping while livingin community setting. Facilitate discharge planning for patients, involving support systems when possible, to provide level of intervention that creates environment for crisis contacts and safe community living. Interface with team to determine multidisciplinary assessment of discharge planning needs and provide information regarding support system/family function. Update Interqual. Other duties as assigned. Typical case load is 10 patients. Consult/Liason Job Responsibilities/Activities Primary responsibility is to complete assessments in ED and discharge planning for patients within the hospitals. Secondary responsibility is discharge planning assistance for psychiatric followup for patients being treated for a medical condition. Complete crisis assessments to determine level of care required for patient to move to safe community living including but not limited to reason for presentation, current symptoms and level of distress, ability to participate in treatment, safety assessment, past history of treatment, current support systems, strengths, weaknesses and primary psychiatric diagnosis. Facilitate discharge planning with psychiatric appointments or referrals to other facilities as determined by level of care needed. Facilitate tracking of IVC paperwork for all patients who are awaiting transfer to another facility. Interface with team for cases covered by consult service to determine multidisciplinary assessment of discharge planning needs and provide information regarding support system/family function. Update Interqual for patients who are not being treated for a medical condition (typically observation patients at Duke Raleigh). Case load varies as immediate needs vary. As a guide, 3 initial assessments and discharge planning activities for up to 6 patients could be completed during 8 hour shift. Pediatric cases take longer to complete initial assessment so the total number would be reduced if a patient is under 18. Provide community liaison to one mental health workgroup.

Knowledge, Skills and Abilities

Ability to work effectively in a self-directed role Ability to multi-task, capable of daily problem-solving complex issues Excellent written and verbal skills Basic computer skills necessary

Level Characteristics

N/A

Minimum Qualifications

Education

Master's degree in social work from an accredited school of social work.

Experience

3 years of relevant experience.

Degrees, Licensures, Certifications

Current licensure as a licensed clinical social worker (LCSW) by the NC Social Work Certification and Licensure Board. Consult/Liason should also be a Notary.

Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.

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About Duke University Health System

As a world-class academic and health care system, Duke Health strives to transform medicine and health locally and globally through innovative scientific research, rapid translation of breakthrough discoveries, educating future clinical and scientific leaders, advocating and practicing evidence-based medicine to improve community health, and leading efforts to eliminate health inequalities.

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