Inpatient Social Work, Care Transitions

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

As a core member of the interdisciplinary care team, the social worker effectively collaborates to actively address the coordination of post-acute care services and the provision of psychosocial support services to patients and families. Serves as a resource for the health care team on appropriate and effective disposition that reduces the length of stay and readmission.

Job Description:

Assessment and Planning:

As a member of the interdisciplinary care team, identifies high-risk psychosocial factors of patients/families that impact status and discharge planning.

·         Educates the care team on the impact of social drivers of health (SDOH) on medical treatment and care planning.

·         Develops a psychosocial assessment, and intervention plan regarding identified patient and family needs utilizing all available sources of information.

·         Participates in inter-disciplinary and inter-agency collaborative efforts to identify and coordinate care, treatment and post-acute care needs.

·         Psychosocial assessment includes social, economic, cultural, age-related, and behavioral factors.

·         Demonstrates competency in knowledge of community resources to address identified needs.

·         Provides crisis intervention and counseling services to assist patients and families with their emotional needs and adjustment to the medical episode.

·         Provides accurate, timely, and appropriate documentation of all social work assessments and interventions in the electronic medical record per regulatory policies and procedures.

·         Assesses and screens patients for interpersonal violence (child, adult, elder).  Provides education and facilitates reporting by interdisciplinary team members per hospital policies.

·          Provides education and facilitates reporting by interdisciplinary team members with direct knowledge of patient condition and events of concern.

·         Screen and identify SDOH risk factors that contribute to readmission, such as inability to access medications, lack of transportation, insurance status, etc.

Care Coordination/Care Transitions

As a member of the Care Transitions, the inpatient social worker collaborates with care providers and third-party payors to ensure that all appropriate services and resources are utilized in a timely and efficient manner.

·         Actively participates in multidisciplinary rounds (MDRs) and care conferences on assigned units and assists with documenting all pertinent information in the medical record.

·         Establish her/himself as an integral part of the team and present each day in the units to which they are assigned.

·         Maintains timely communications with third-party payor representatives to identify discharge needs and available resources.

·         Seeks out members of the treating team to identify the most efficient/effective plan to progress care and offers to assist with the identification of resources to facilitate the plan of care.

·         Provides patient/support system education and resources regarding options for care and completes relevant referrals to health agencies, mental health facilities, counseling services, social agencies, post-acute care providers, and disease or condition-specific resources in an effective and timely manner based on the patient condition/needs to minimize delays in patient receipt of services.

·         Demonstrates expertise in facilitating end-of-life discussions and issues, including goals of care, hospice, and palliative care.

·         Demonstrates expertise in addressing advance directives, power of attorney, health care representative, and guardianship issues and serves as a resource to the interdisciplinary health care team consulting with Legal as needed.

·         Maintains working knowledge of in-house and community resources and awareness of legal/risk issues related to care planning.

·         Identify and utilize appropriate interventions to