Elliot Health Systems - Social Worker Care Coordinator MSW - Pathways - Full Time

Description

Social Worker Care Coordinator Pathways

POSITION SUMMARY

The Inpatient Behavioral Health Social Worker cares for adult patients with acute and chronic psychiatric disorders; maintains a safe patient care environment;

assesses and evaluates the patient’s health status and patient / family significant other’s response to illness. Coordinates and guides plans of care to expedite recovery and discharge of patient.

Provides clinical interventions with patients, and families that address personal and environmental issues in order to maximize emotional, social and physical well-being and the appropriate and efficient use of health care services across the continuum.

Promotes efficient coordination of patient care through collaborative practice with the health care team. Promotes patient, family, staff and physician satisfaction through coordination and continuity of care.

Provides a systematic approach to evaluation of patient care. Coordinates patient care through the continuum thereby facilitating the achievement of optimal quality outcomes in relation to clinical care and cost effectiveness.

KEY RESPONSIBILITIES

Patient Facilitation

Collaborates and participates with the primary nurse and the multidisciplinary team in the ongoing clinical social work assessment of patient’s status / care management.

Participates in the development, implementation and evaluation of integrated clinical pathways.

Provides supportive counseling and crisis intervention for patient / family as needed.

Monitors patient’s progress to ensure care is appropriate and timely.

Assists the Health Care Team in the coordination of care on the unit by serving as a resource to staff and assisting in day to day psychosocially based problem resolution.

Participates in daily unit rounds.

Provides counseling and assistance with Advance Care Directives.

Advocates for the patient to ensure quality outcomes.

Coordinates and facilitates family meetings.

Respects the dignity and confidentiality of the patient and all verbal / written information / communication.

Conducts Education / Support Groups for patients / families as assigned.

Provides emotional support to patient / family to facilitate adaptation to illness / disability.

Utilization Management / Managed Care

Intervenes with appropriate individuals / department regarding delays in service that may have an impact on quality of patient care and / or length of stay.

Collaborates with case manager to assess for patient’s clinical course to verify patient’s continued need for acute hospital level of care.

Explores strategies to reduce length of stay and resource consumption with optimal patient outcomes.

Interprets federal and state regulations pertaining to coverage issues and provides education to patient and family.

Quality Management

Conducts assigned quality management activities to improve patient care and service.

Participates as part of the interdisciplinary team in the development or revision of hospital policies / procedures pertaining to patient care processes.

Assists in the identification of organizational priorities for improvement.

Identifies and collects clinical data in support of quality, risk management, utilization, infection control and resource utilization etc.

Participates in multidisciplinary meetings to review activities / outcomes / issues related to assigned unit.

Facilitates multidisciplinary teams as assigned.

Serves as a resource for process improvement tools and technique.

Discharge Planning

Assesses patient / family adaptation to illness / disability and capacity to provide for patient’s care needs via biopsychosocial assessment.

Serves as a resource / liaison to community social service agencies relative to identified patient / family needs. Serves as a resource to the interdisciplinary team for discharge planning options through daily rounds and discharge planning rounds.

Addresses financial concerns which may impact discharge planning and optimal patient care.

Supports the Case Manager in the development of a comprehensive discharge plan for socially complex patients.

Collaborates with community social services agencies to enhance discharge planning and continuity of care.

Facilitates and coordinates non-medical / social / culturally complex discharge planning, including but not limited to Hospice, Nursing Home Placement, Homemakers and Community based Social Services.

i.e. HCBC, Adult Day Care, In Home Adult Care, Companion Program, Emergency Responses Systems etc).

EDUCATION / EXPERIENCE / LICENSURE

• Education : Master of Science in Social Work or Master degree in a closely related field required.
• Experience : One (1) to three (3) years of experience in a health care system, preferably in a hospital setting.
• Certification / Licensure : LICSW Preferred
• Schedule : General Monday through Friday, day shift, may rotate to weekends, evenings and nights to meet total program needs.
• Other : Approved Aggression de-escalation training required.

Work Shift : Days full time

Days full time