Inpatient Social Work, Care Transitions-2

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

Job Description:

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. 

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