Social Worker I | Case Management

Overview

At Houston Methodist, the Social Worker I (SW I) position provides comprehensive, compassionate, clinical social work and discharge planning to patients and their families of a targeted patient population on a designated unit(s). In collaboration with physicians and the interprofessional health care team, this position sensitizes other health care providers to the social and emotional aspects of a patient's illness to facilitate efficient, quality care and achievement of desired treatment outcomes. The SW I position holds joint accountability with Case Manager for discharge planning and continuity of care, assuring that psychosocial issues are addressed and treated as needed across the continuum of care.

Houston Methodist Standard

PATIENT AGE GROUP(S) AND POPULATION(S) SERVEDRefer to departmental "Scope of Service" and "Provision of Care" plans, as applicable, for description of primary age groups and populations served by this job for the respective HM entity.

HOUSTON METHODIST EXPERIENCE EXPECTATIONS

• Provide personalized care and service by consistently demonstrating our I CARE values:
  • INTEGRITY: We are honest and ethical in all we say and do.
  • COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
  • ACCOUNTABILITY: We hold ourselves accountable for all our actions.
  • RESPECT: We treat every individual as a person of worth, dignity, and value.
  • EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.

• Practices the Caring and Serving Model

• Delivers personalized service using HM Service Standards

• Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)

• Intentionally collaborates with other healthcare professionals involved in patients/customers or employees' experiential journeys to ensure strong communication, ease of access to information, and a seamless experience

• Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

• Actively supports the organization's vision, fulfills the mission and abides by the I CARE values

Responsibilities

PEOPLE ESSENTIAL FUNCTIONS

• Communicates in an active, positive and effective manner to all health care team members and reports pertinent patient care and family data in a comprehensive and unbiased manner; listens and responds to the ideas of others. Uses therapeutic communication to establish a relationship with patients and families and communicates the discharge plan, facilitating transitions and hand-offs. Supports patients and families in clinical or ethical issues.

• Uses patient and family-centered approach in collaboration with interprofessional health care team. Facilitates discharge planning activities for assigned patients and collaborates with the case manager and other members of the interprofessional health care team, as well as patient and family. Maintains ownership of the psychosocial component, assessments, diagnosis and treatment, of the discharge planning process on assigned units.

SERVICE ESSENTIAL FUNCTIONS

• Serves as a unit-based participant for comprehensive case management activities including assessing patients and collaborating with team to identify at-risk patients, participating in daily Care Coordination Rounds, and identifying any barrier(s) of efficient patient throughput.

• Develops and implements a comprehensive psychosocial treatment plan utilizing appropriate clinical social work diagnoses, treatments and interventions, including crisis intervention, brief individual, marital and family therapies, and patient, family and caregiver groups. Assists with screening, identification, diagnosis, management and treatment of victims of abuse, neglect, and domestic violence and of mental health and/or substance abuse problems in patients and family members.

• Completes a full assessment based on the social work assessment, identifying social determinants of health. Completes screening by patient/family interview, review of the medical record including previous episodes of care, H&P, lab and other test results/findings, plan of care, physician orders, nursing and progress notes. Uses clinical knowledge and screening tools to identify need for case management and/or social work intervention.

• Establishes mutual educational goals with patient and family, provides appropriate resources, incorporating planning for care after discharge.

• Uses knowledge of levels of care, working with patient and family, to ensure discharg