Social Worker, Care Management DV

Overview

Social Worker, Care Management 1.0DV ) -

Provides psychosocial assessments, diagnosis, and treatment, as well as discharge planning to and consultation about patients and families to assist them and the health care team in coping with patient’s hospitalization, illness, diagnosis, treatment, and/or life situation, including emotional, mental, and substance abuse disorders in both the Specialty Clinics and inpatient setting.

• Maintains established hospital and departmental policies and procedures, objectives, performance improvement program, safety, environment of care, management of information, and infection control standards. (1,5)
• Utilizes excellent customer service skills at all times. (1,5)
• Complies with federal and state law and accrediting and licensing agencies at all times, to include but not limited to, JCAHO and federal compliance regulations. (1,5)
• Participates and implements discharge planning activities for complex patients, in order to ensure a timely discharge and to provide appropriate linkage with post-discharge care providers. Receives referrals for complex patient problem resolution from Case Managers or care team members. (1,2,3,4,5)
• Screens and coordinates all new Nursing Home, SNF post dialysis placements, and Hospice facility referrals. When necessary, makes recommendations regarding facilities to be removed from the hospital’s referral resources catalogue. (1,2,3,4,5)
• Communicates with and assists case managers with the discharge planning status of all patients referred by them. (1,3,5)
• Validates discharge criteria for patient and families and notifies Case Managers of newly-identified resources or change in previously-identified resources. (1,3,5)
• Follows-up with patient, family and/or facility post discharge as indicated to ensure appropriate disposition and follow-up care. (1,3,5)
• Assesses patients' and family’s psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope. (1,2,3,4,5)
• Provides intervention in child abuse/neglect, domestic violence, guardianship temporary/permanent) foster care, adoption, mental health placement, advance directives, adult/elderly abuse, child protection and sexual assault. (1,2,3,4,5)
• Formulates, develops, and implements a comprehensive psychosocial treatment plan utilizing appropriate clinical social work treatments and interventions. Interventions may include crisis intervention, supportive counseling and brief therapy. (1,2,3,4,5)
• Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability; accesses and mobilizes family/community resources to meet identified needs. (2,3,5)
• Assures patients and families receive the appropriate cultural attention in all aspects in the delivery of care. Identifies and supports patient and family spiritual needs. (2,3,5)
• Serves as a resource person and provides support and resource information related palliative care treatment decisions and end-of-life issues. (2,3,4,5)
• Participates in and leads patient/family care conferences and records and appropriately manages patient and family concerns as appropriate. (2,3,5)
• Maintains awareness of relevant payor requirements and partners with case managers, physicians and other healthcare professionals to address any issues related to denials and clinical appropriateness of admission and continued stay. (1,3,5)
• Screens for financial needs and refers to appropriate personnel and/or programs. Communicates reimbursement information to patients and families. (1,3,5)
• Participates in data collection and outcomes management for all departmental activities (e.g., LOS, cost management, denial management, and avoidable days). (1,3,5)
• Communicates and coordinates findings and care recommendations effectively and collaboratively between disciplines to achieve targeted outcomes. (2,3,5)
• Mantains a working knowledge of and ensures continuity of care by acting as a liaison between the various healthcare professionals, community agencies and resources. (2,3,5)
• Assists with appropriate…