Overview
The Social Worker (MSW or BSW) will ensure patient progression through the continuum of care in an efficient and cost-effective manner. Responsibilities will include utilizing expertise in patient/family assessment incorporating physical, psycho-social, environmental, spiritual, and financial factors to create a sound discharge plan; reducing length of stay and readmissions; utilizing psychosocial assessment skills and crisis intervention techniques to expedite and support healthcare team's work with patient/ family; and collaborating with the RN Case Manager to identify and initiate the most efficient discharge plan to expedite the patient transition to the next appropriate level of care and to reduce length of stay. This position is the organization's expert in assessing and managing the patient's psycho-social needs of hospital patients. The Social Worker educates the health care team and physicians about psycho-social issues and identified patient/family problems as well as recommends strategies to address these issues.
Responsibilities
Completes a face to face assessment of all new patients in caseload within 24 hours or next business day to identify appropriateness for inpatient rehabilitation, level of care and to anticipate high level care planning needs. Screens high risk patients with lace score greater than or equal to 10 to reduce 30 day readmissions. Consults with attending physicians regarding potential care transition barriers identified as a result of this process.
Assumes transition process in collaboration with the multidisciplinary team and patient/family and assists with executing the plans and interventions to facilitate the stay and manage length of stay.
Facilitates patient care conferences/complex case conferences proactively as needs are identified to reduce avoidable readmissions and length of stay.
Identifies and reports process improvement opportunities by capturing delays in care by documenting avoidable days in MIDAS per guidelines.
Provides an Important Message notice and choice on Medicare patients as appropriate.
Monitors and facilitates appropriateness of tests/procedures, consultation, treatment plans and resource utilization.
Implements the care transition through service referral and assures that the patient is given choice in regard to agencies and services.
Maintains contact with the patient, family, RN, physician, therapy team, and other appropriate team members to ensure the most cost effective plan of care is being carried out and appropriate in network providers are being utilized.
Implements the care transition through service referral and coordination activities. The Social Worker always assures that the patient is given the choice in regard to agencies and services.
Provides information about resources and options available in the community and coordinates service delivery. Interprets patient/family needs and provides information concerning the availability and limitation of resources.
Maintains functional working relationships with community providers.
Identifies and reports process improvement opportunities.
Coordinates and collaborates with other healthcare professionals in weekly interdisciplinary team conference.
Provides factual information based on current knowledge, to provide psychosocial support and assist the patient/family in coping with their disease to improve their overall health care management
Establishes a comprehensive discharge care transition for inpatients with post-acute care needs. The Social Worker will organize, secure, integrate, and modify the resources necessary to meet the goals in the stated care transition. The Social Worker will monitor patient care across the continuum through follow-up with patients, families, and community services. Provides clear and timely information on the patient’s plan of care to the next provider, as appropriate.
Documents plan of care and updates /changes in plan of care in the electronic medical record.
Educates the patients/family by intervening, negotiating, and promoting their concerns. Problems requiring advocacy may include individual and class inequities or inadequate and non-existent hospital and/or community resources, such as insurance benefits, housing etc.
Serves in obtaining legal guardianship, competency determinations, adoption related situations and all cases where Adult abuse is a concern. Is responsible for making sure all legal documents are completed. Collaborates with the Director of Rehab Services as needed.
Provides counseling and support as needed. Identifies cases which would benefit from palliative care and elicits palliative consults as needed.
- Maintains pertinent and timely documentation in the Wellsky, Meditech, and Midas systems
Collects and