Position Summary: Provides assessment and intervention to assist clients/families to improve social and economic difficulties interfering with health and wellness through use of casework process and principles, strategies, and community resources. Provides professional discharge planning services through assessments, and coordination of post hospital care needs to patients and their families; providing them with resources and choices to effectively link them to the needed level of emotional, medical and spiritual care. Receives referrals for individuals from at-risk populations from interdisciplinary team members.
Essential Functions and Responsibilities as Assigned:
1. Performs high level triage of all patients, with focus on identifying those with complex psych-social or financial issues, placement needs and community service needs within 24 hours of admission.
2. Receives RN Care Manager referrals to social work based on identified Social Work Triggers (see SW Referral Standard Operating Procedure - SOP).
3. Identifies and assesses barriers early in the patient’s stay, formulating a plan with the patient, family, internal and external members of the healthcare team, payers, and community resources. (e.g., LOS barriers to D/C)
4. Assesses patient and family needs for support and community service needs (Meals on Wheels, Sitters, etc.); educates and refers them to community resources, access to services, arrange for appointments and establishes rapport with other agencies.
5. Assesses risk of readmission for specified patient populations and initiates assigned interventions that will enhance the patient’s ability to successfully transition along the care continuum.
6. Identifies the need for, arranges, and participates in family care conferences; participates in interdisciplinary conferences and provides consultation for patient, families, and clinical staff (e.g., attends care conferences/unit rounds/huddles).
7. Identifies and reports avoidable day/variances and/or service delays from established plan of care to leadership.
8. Identifies patient and family preferences, needs and strengths, to foster for the interdisciplinary team in compliance with standards of care.
9. Interviews patient and significant others to assess patient’s psychosocial situation and identifies which family member is the point of contact.
10. Develops discharge plan in direct consultation with patient, family, physician, and health care team.
11. Manages complex cases/situations and intervenes with and advocates for patients and families as plan of care and discharge plan are developed. Complex discharge planning identified from SW triggers (see SW Referral Standard Operating Procedure - SOP)
12. Uses knowledge of insurance benefits and coverage guidelines to maximize appropriate utilization of resources.
13. Documents in the EMR: assessment, plans, interventions, barriers, and reassessments as necessary to facilitate discharge and/or transitions; ensures all pertinent information is transferred to post-acute agency.
14. Works collaboratively with the RN Care Manager, other disciplines, and internal and external members of the healthcare team to ensure a safe, appropriate, and timely transition to the next level of care, taking into consideration the patient’s available resources.
15. Partners with external agencies and facilities to provide continuity of care for patient and family empowerment and independence to make autonomous health decisions.
16. Represents the integrated care management department on various teams and performance outcomes committees and projects.
17. Performs other related duties as required and directed.
Qualifications:
Required:
• Licensed Master’s Social Worker (LMSW); LMSW certification within one year of eligibility and maintenance of continuing education requirements
• American Case Management Certification (ACM) or obtain certification when eligible as defined by the Association Case Management Association, and maintenance of continuing education requirements.
Preferred:
• Certification in Case Management Certification (ACM or CCM)
• Three years acute hospital care or social work experience
• Basic Life Support (BLS) certification as a Healthcare Provider by the American Heart Association, American Red Cross or equivalent through the Military Training network (MTN)