The Social Worker is responsible for coordinating the facility placement, community agency referral and social coping aspects for 100% of the assigned patient populations. They will serve as a direct provider, referral source and resource to other staff in an effort to promote the delivery of high quality, fiscally responsible continuing care services. The Social Worker will provide professional social work services to patients, families, and/or caregiver(s), which reflect the biopsychosocial needs of the patient and enable him/her to achieve an optimal level of health in accordance with social work practice and hospital policy and procedures. The Social Worker will perform other related duties as required or directed.

ACCOUNTABILITIES
*All duties listed below are essential unless noted otherwise*
1. Initial Assessment is to be completed within 24-48 hours of admission.
2. Reviews assessments of medical staff and continuing care coordinators.
3. Compiles the information as a basis for formulating and implementing discharge plans which reflect the clinical and social needs of the patient within 24-48 hours of admission.
4. Meets with patient and contacts family members within 24-48 hours to gather additional information necessary to enact discharge plans as well as to convey information to the patient.
5. Recommends amendments to the discharge plan after completing necessary assessments and data gathering.
6. Participates in multidisciplinary treatment team meetings to assist the patient, as scheduled.
7. Monitor feedback from Social Work Assistant during treatment team and provide direction as needed.
8. Initiates discharge placement options and identifies facilities which reflect the needs of patients from a clinical as well as financial perspective. Educates patients and families regarding the facility placement process and the related options.
9. Communicates with the Community Mental Health Centers within 48 hours, or the next business day. On-going communications must be provided and documented.
10. All contacts with patients are to be documented in the patient care notes.
11. Patient contact is to be made daily. Weekends may be modified as the need dictates.
12. Ensures all necessary paperwork is completed at least 24 hours prior to facility placement.
13. Ensures appropriate transportation is arranged for patient discharge.
14. Identifies patients with financial limitations requiring financial counseling and application to welfare agencies. Makes referrals as indicated.
15. Provides individual and group counseling as required. Family counseling is initiated as indicated.
16. Facilitate at least 3 weekly patient counseling/educational group meetings.
17. Primary responsible for facilitating effective discharge planning.
18. Must assess patient’s suicidal/homicidal potential and take appropriate actions.
19. Must utilize good communication skills and current treatment modalities in 1:1 interventions and group facilitation.
20. Must be able to implement the seclusion and restraint process according to department policy.
21. Develops, initiates, and maintains patient programming and therapeutic milieu.
22. Documentation of interactions with patients to be completed in a timely manner, but never to exceed the same day of interaction.
23. Processes consultation from Nursing Units and Emergency Department, when needed.
24. Assess patient condition and social service needs.
25. Initiates referrals as indicated, ensures necessary paperwork is completed and documents accordingly. Provides feedback to referring department regarding patient disposition.
26. Serves as a resource to Nursing Unit and Emergency Department staff regarding appropriate selection of patient for referral to social services.
27. Keeps abreast of current professional standards of the social work field and makes recommendations on changes in policy, procedures, equipment, and programs.
28. Develops and maintains working relationships between nursing units, continuing care department, hospital administration, medical staff, and all other hospital personnel.
29. Develops in-service programs in conjunction in other hospital personnel regarding the social, emotional, and cultural aspects of illness and their effect on patients and families.
30. Provides consultation to members of hospital staff, community agencies, and other persons or groups seeking guidance in efforts to solve the problems of patients, or in developing social work programs in health care settings.
31. Maintains working relationships with community health, welfare, and social agencies.
32. Participates in activates of professional associations including internal and external committee activities.
33. Identifies and follows through in customer satisfaction issues with goal of promoting a sense of continuity of care and a climate of concern for individual/family welfare.
34. Provides leadership in team building for all staff. Is viewed as a positive, professional role model.
35. Develops and maintains a comprehensive mental health network with agencies and individuals.
36. Is an advocate for patients and family rights.