Employment Type:

Full time

Shift:

Description:

GENERAL SUMMARY

Provides care coordination, education, transition management and outreach services to high-risk or high utilizer patients.  Assists these patients and their families in coping with problems associated with chronic and long-term illnesses across the continuum of care.  Conducts patient and family interviews to identify biopsychosocial and environmental needs, identifies and addresses barriers to patient achieving optimal health care status, such as lack of appropriate housing, transportation, utilities, food, etc. Enlists appropriate community resources to address identified needs.  Provides consultation to patient treatment team members and participates in developing new patient care programs.  Provides quality patient care considering age specific, developmental, cultural, spiritual, diversity, and/or other special needs or circumstances through competent clinical practices. 

PRINCIPLE DUTIES AND RESPONSIBILITIES

• Functions as a member of the interdisciplinary care management team.
• Interviews patients and families to obtain psychosocial data. Evaluates and gather data from the patient, family, outpatient supports and other collateral sources (including the primary care provider) regarding plan of treatment and available resources and develops an appropriate intervention plan.
• Provides a variety of direct services and clinical interventions in order to provide continuity of care and to help patients and families resolve socio-emotional problems associated with adjustment to illness, resource needs, mental health problems and a variety of life events and transitions.
• Coordinates care of identified high-risk patient population across continuum, addressing biopsychosocial and environmental barriers to optimal health status.  In collaboration with patient, family, primary care provider, and any involved community agencies develops plan to address and manage issues which influence health care utilization.  
• Refers patients to designated community agencies or resources for financial assistance, counseling, mental health and substance abuse follow-up, and other support services.
• Conducts continuity of care planning for assessing needs and support services.
• Provides ongoing assessment of educational needs of patient/family and develops appropriate interventions and programs in response. Maintains good working relationships with community resources.  Demonstrates ability to make appropriate and useful changes in the patient’s treatment plan when problems persist and recognizes when discharge and/or transfer of care is in the best interest of the patient.
• Advocates, educates, and facilitates resolution of patient rights, ethical and legal issues such as advance directives, end of life decisions, guardianship, etc.
• Systematically identifies and addresses barriers and fragmentation of care while proactively/collaboratively problem solving to find solutions.
• Documents social work assessment data and progress notes for each patient including nature of psycho-social concerns, patient and family supports and needs, and intervention plan in accordance with department documentation standards.
• Provides consultation to other patient treatment team members regarding socio-emotional factors that affect patient’s condition, treatment plan and recovery.
• Regularly communicates with other departmental and community agency personnel to coordinate social work functions and other services, exchange patient information, and ensure continuity of care.
• Acts as liaison between inpatient and outpatient care settings to ensure continuity of care throughout each site of care, and to ensure communication about and adherence to the established plan of care for each patient.
• Utilizes pertinent population data to identify trends, potential areas of targeted intervention. Uses metrics to establish measurable goals and monitor outcomes.  Uses professional expertise to advance policies and practices that improve access to care, ensure timely follow-up care and supports the delivery of evidence-based clinical management.
• In conjunction with identified leadership, develops, implements and monitors clinical quality improvement processes within a specific population and/or program.  Regularly prepares and presents written reports that track, monitor and measure outcomes of interventions to address patient/population needs and identify and remove barriers. 
• Provides Social Worker leadership in related committees, task forces and work groups with a focus on improved health outcomes for the populations served.  Serves as a change-agent and resource to foster adoption of process/service/system improvement initiatives at various points of serv