Social Worker II-MSW

To provide services to The Christ Hospital patients and families by assessing psychosocial needs and implementing a discharge plan of care to assure continuity of the patient’s care. Provides psychosocial interventions, advocacy and linkage with community resources.

ASSESSMENT/SCREENING

• Assess patients’ evolving medical situation from a psychosocial framework, including functional status, goals of care, and community support needs as it relates to discharge planning
• Assess family structure, dynamics, and decision-making preferences, including identification of a surrogate decision maker if needed
• Assess patient/family environmental risk factors, patient/family/community support systems, age-related/developmental issues, financial barriers, health literacy, chemical dependency/mental health, Social Determinants of Health needs, and any risk of abuse/neglect/financial exploitation/intimate partner violence
• Assess for risk of readmission, putting into place a coordinated plan for outpatient follow up

DOCUMENTATION

• Documents in Discharge Planning progress notes a clear, concise, objective psychosocial assessment, treatment plan, and progress of social work intervention and outcomes in compliance with regulatory standards and department standards for timeliness.
• Documents appropriately in the Social Work module for data tracking purposes

DISCHARGE PLAN IMPLEMENTATION/CARE COORDINATION

Develop a plan of intervention, which is integrated with the interdisciplinary treatment team to establish continuum of care in congruence with ethical and legal considerations.

Implements plan of care:

• Provide psychosocial counseling and other therapeutic interventions for patient/family
• Provide crisis management for patient/family
• Facilitate healthcare decision making and resolution of discharge planning issues
• Provide psychosocial intervention for: neglect/abuse/intimate partner violence/human trafficking; adjustment to illness; bereavement and mental health; substance abuse; non-compliance, and other psychosocial barriers to diagnosis and treatment
• Mandated reporting to local/state agencies as required by law – Adult Protective/Child Protective Services, law enforcement
• Maximize health status and minimize length of stay and appropriate utilization of hospital resources
• Provide referral and linkage to health care and community resources based upon Social Determinants of Health screening needs
• Facilitate extended care facility placement and hospital to hospital transfer
• Facilitate home care, hospice care, and durable medical equipment arrangements
• Advocate, mediate and negotiate a cohesive plan for maintaining or improving social supports and patient safety
• Coordinate patient’s discharge plan with outpatient counterparts – TCHMA SW, insurance case managers, community mental health/substance abuse case managers – to aid in readmission prevention

CONSULTATION/EDUCATION/COLLABORATION

• Attend unit specific interdisciplinary rounds daily 
• Collaborate with interdisciplinary team to enhance quality of care and efficiency.
• Maintain a positive working relationship with healthcare team and community agencies and services.
• Provide extensive education to patient/family in areas of insurance benefits, and capacity of community resources to meet patient needs
• Participate in interdisciplinary patient care rounds, case conferences and family conferences for purpose of appropriate length of stay discharge planning.
• Assist interdisciplinary team in understanding significant social and emotional factors related to illness.
• Identify barriers in service delivery systems and advocate for change.
• Provide education to interdisciplinary team, residents, students, other disciplines and community agencies
• Evaluate patient outcomes and participate in process improvement.

CONTRIBUTIONS TO THE SOCIAL WORK DEPARTMENT

• Provide leadership and perform delegated management responsibilities.
• Provide clinical supervision to peers, Bachelor degree staff, and students.
• Provide mandatory and/or voluntary cross coverage when needed.
• Participate in orientation of new staff.
• Generate and support ideas to improve Social Work Department service delivery systems.
• Identify complex clinical cases and seek supervision when appropriate

OTHER SERVICE-SPECIFIC DUTIES

KNOWLEDGE AND SKILLS: 

Exceptional skill interviewing patients and families in crisis and individuals with a wide range of physical and emotional problems. Ability to prioritize many simultaneous demands. Medical and psychiatric