Assess inpatient discharge needs, safety needs in coordination with Clinical Therapist and treatment team members. c. 123 upon discharge, Assists inmates with special needs, including, but not limited to, dialysis, mobility impairments, sensory impairments, cognitive impairments, and need for assistive devices (e.g., wheelchairs), Identifies inmates with medical and mental health conditions who would qualify for MassHealth disability and completion of the Disability Supplement Application, Identifies housing placement, such as nursing home placement, as needed, Assists the DOC Correctional Program Officers (CPOs) in securing appropriate housing for inmates identified as having a medical or mental health impairment of such significance as to require special housing needs, Makes referrals for post-acute services under the direction of the RN Case Manager or Social Work (SW) staff utilizing the electronic Tenet Case Management system, Provides patients and families with choices of post-acute providers per Tenet policy, Responds to post-acute providers timely and completes referrals per Tenet policy, Documents and communicates all elements of the post-acute referral to the RN Case Manager or SW and the healthcare team, patient/family and post-acute providers, Completes tasks as assigned by RN or LVN Case Manager and/or SW staff, Makes copies, send faxes and complete phone calls to arrange post-acute services and to ensure that appropriate hospital information is communicated to post-acute providers, Compliance- Adheres to federal, state, and local regulations and accreditation requirements impacting case management scope of services, Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and Tenet policies, Documents all referrals and tasks in the Tenet Case Management system per Tenet policy, Education Provides patients and healthcare team information regarding resources and benefits available to the patient along with the economic impact of care options, Facilitates discharges scheduled for the weekend; which includes verification of plan with multidisciplinary team, Collaborates and maintains active communication with physicians, nursing and other members of the interdisciplinary team to effect timely, appropriate discharge planning, Proactively identifies and resolves delays and obstacles to discharge, Facilitates patient management throughout hospitalization, Participates in patient management rounds and patient centered meetings, Identifies potential delays and resolves issues with appropriate departments, Identifies appropriate utilization of Social Work Services and makes referrals when appropriate, Collaborates with and provides feedback to the primary care physician and multidisciplinary team regarding patient’s status with regard to length of stay, utilization of resources and discharge status, Provides support to the in-patient health care team as well as to patient and family regarding all aspects of admission, hospitalization and discharge plan, Ensures patient and/or family are given information regarding their choices regarding transferring the patient to another level of care according to regulatory standards, Performs concurrent utilization management using Interqual criteria, Provides appropriate and timely discharge planning from the hospital, arrangements for follow-up health care, assessment of financial resources available for patients, and referrals to appropriate community resources as needed, Accurately assesses patient's financial resources, makes referrals to community groups to provide assistance as needed, and coordinates transfers to extended care facilities (ECF), group care homes, or other acute hospitals as appropriate, Functions as a member of a multidisciplinary case management team, Participates fully as a member of the social and pastoral services department, Participates in the patient satisfaction survey, Receives notification of admission of patients and referrals, Performs case management interventions as directed by the treatment team, Contacts and schedules appropriate discharge appointments, including but not limited to: residential placement; long-term hospitalization; psychiatric outpatient services and outpatient therapy. 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