Social Worker LMSW - Care Management

Social Worker LMSW - Care Management

JOB SUMMARY

The Social Worker is responsible for creating outcomes for the patient and family by managing complex psychosocial and economic co-morbidities. Provides education and consultation regarding resources, collaborates to develop a discharge plan and facilitates and monitors its implementation. Assists patient / family adjust to and cope with illness, diagnosis, treatment options, and prognosis. Through advanced practice skills mobilizes resources to reduce risk, serves as a liaison between the hospital and the community. In addition, offers crisis interventions to patient / family. Strives for superior performance by consistently providing a product of service to leadership and staff that is recognized as ultimately contributing to the patient and family experience. As a customer-focused Memorial Healthcare team member, he / she must be accessible, flexible, knowledgeable, and responsive.

JOB RELATIONSHIPS

RESPONSIBLE TO : Director of Hospital Throughput, Associate Manager of Social Work

WORKERS SUPERVISED : None

INTERRELATIONSHIPS : Case management department staff; other hospital departments; Medical staff; patients; families; external agencies

PRIMARY JOB RESPONSIBILITIES

• Psychosocial Assessment and Interventions
• On the basis of preliminary risk screening, assesses patient and family psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness, and ability to cope.
• 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.
• Provides intervention in cases involving child abuse / neglect, domestic violence, elder abuse, institutional abuse, and sexual assault.
• Serves as a resource person and provides counseling and intervention related to treatment decisions and end-of-life issues.
• Discharge Planning
• Participates in discharge planning activities for complex patients in order to ensure a timely discharge and to provide appropriate linkage with post-discharge care providers.
• Deals with families exhibiting complex family dynamics that impact directly on patient care and discharge.
• Communicates with healthcare team regarding the discharge planning status of all patients referred by them.
• Assists RN Case Managers or appropriate team members with discharge planning activities as requested.
• Provides consultation to RN Case Manager or appropriate team members when coordination with significant or intensive community resources is necessary to achieve desired treatment outcomes.
• Receives referrals for complex patient problem resolution from RN Case Managers or care team members.
• Screens and coordinates referrals to the next level of care, SNF, LTAC, Hospice and Rehab. Validates discharge criteria for patients and families and notifies RN Case Managers of newly-identified resources or change in previously-identified resources.
• Educates patient / family and physician regarding post-acute options and addresses issues of choice.

Patient and Family Support in Legally Complex Cases

JOB SPECIFICATIONS

1. EDUCATION

2 . EXPERIENCE

3 . ESSENTIAL PHYSICAL REQUIREMENTS

5 . ESSENTIAL TECHNICAL / MOTOR SKILLS

6 . ESSENTIAL SENSORY REQUIREMENTS

7 . INTERPERSONAL SKILLS

8. WORK CONDITIONS

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