Social Service Associate-Care Coordination Full-time Days

Job Description

The Social Service Associate reflects the mission, vision, and values of NM, adheres to the organizations Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.

The Social Service Associate provides quality support, psycho-education, supportive counseling, advocacy, and linkage to community resources.

Responsibilities :

• Completes Care Coordination Assessment within 24 hours of Order to assist with throughput.
• Collaborates with the Interdisciplinary Team to assist with patient satisfaction and discharge plan.
• Ensures discharge plan is initiated at admission.
• Ensures patient is discharged with appropriate referrals so can successfully move within the healthcare continuum and prevent re-admission.
• Is concerned about the perception of patients, families, and the community regarding Northwestern Medicine's Healthcare System.
• Services are focused on addressing behavioral, social, financial, and environmental issues in order to achieve optimum clinical quality, patient satisfaction, and cost effectiveness of care.
• Assesses patients to gather data for bio-psychosocial assessment upon admission and conducts re-assessments as needed.
• Assessments accurately reflect relevant age-specific and cultural-specific factors.
• Assists the patient / caregivers / family in understanding and working through bio-psychosocial and financial concerns as they relate to the patients continuum of care, rehabilitation process, behavioral health treatment, substance abuse, or medical treatment.
• Facilitates patient / family decision-making process for developing an appropriate treatment plan and coordinates with community organizations in order to ensure effective utilization of services.
• Coordinates efforts of patient, family, and healthcare professionals to develop a discharge plan for post-hospital care based on documented bio-psychosocial needs
• Provides continuity of care through referrals and linkage to appropriate community resources based on identified needs.
• Ensures timely discharge planning and throughput initiatives.
• Coordinates post-hospitalization and / or rehabilitation services that may include, but are not limited to home health, home medical equipment, transportation, inpatient behavioral health placement, and nursing home placement.
• Determines and complies with payer requirements in order to ensure maximum coverage for services in the continuum of care.
• Assesses patients for potential abuse / neglect and need for guardianship, takes appropriate action, and follows-up with appropriate community agencies.
• Acts as a patient advocate in all communications with internal and external systems.
• Provides education to patient / family in regards to effective use of community resources.
• Facilitates interdisciplinary care conferences and provides education on psychosocial issues.
• Works collaboratively withpatients interdisciplinary treatment team to identify opportunities for improvement and implement best practice solutions.
• Provides brief, supportive psychotherapy to patient and family at bedside when appropriate, to assist with management of symptoms and engage patient in treatment while hospitalized for medical concerns.
• Demonstrates knowledge of the principles of growth and development over the life span and possesses the ability to assess data reflective of the patients status.

Includes being able to interpret the appropriate information to identify patients age-specific needs

• Completes appropriate documentation and facilitates discharge plan and treatment recommendations for patients. Communicates assessment and clinical findings to the interdisciplinary treatment team
• Provides psycho-education to nursing and medical staff on mental illnesses and substance abuse disorders.
• Acts as a clinical resource for Behavioral Health and Chemical Dependency services to the other service lines within Northwestern Medicine.
• Works collaboratively with medical and nursing staff to share necessary information regarding specific patient care issues and to coordinate intervention strategies.
• Participates in System wide initiatives on Social Service issues.
• Helps to develop Processes and materials that support an understanding of these issues.
• Demonstrates knowledge and skills in provision of services to varied populations including pediatric, adolescent, and adult patients with a wide variety of medical diagnoses.
• Ensures prompt response to patient, discharge, and referral needs.
• Consults with the Attending Psychiatrist to determine if a Patient Safety Companion can be discontinued after the completion of a risk assessment when requested.
• Consults with the patient's Attending Physician to determine if the patient needs to be reported to the Firearms Owners Identification Database (FOID) after the completion of a risk assessment.
• Remains apprised of evidence-based practices and maintains a network of professionals to exchange ideas and benchmark best practices.
• Flexible with working in various units or Hospital sites to meet patient needs
• Actively maintains confidentiality for patients and their families as outlined in the Northwestern Medicine Patient Confidentiality Policy and shows the same level of respect for every Associate within Northwestern Medicine.
• Adheres to and is responsible for the safety standards of Northwestern Medicine including the completion of the mandatory organizational safety standards on an annual basis.

Qualifications

Required :

• Masters Degree in Counseling, Psychology, Social Work, or a Human Services related field is required.
• Psy. D. is also acceptable.

Preferred :

Three years of assessment, admission, and crisis intervention experience with Behavioral Health and / or Chemical Dependency patients in an acute care / medical setting.

Additional Information

Northwestern Medicine is an affirmative action / equal opportunity employer and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.