Evaluates and develops a plan of care personalized to fit the patient's emotional and social needs;
Assesses the patient's social and emotional state as it relates to his/her illness or injury, needs for care and his/her response to treatment and adjustments to care;
Assesses any relationships of the patient's medical and nursing/therapy needs in the home setting, financial resources and available community resources;
Provides appropriate action/intervention to obtain available community resources to assist in resolving issues that may be impeding the patient's recovery;
Instructs patients and families in treating and coping with social and emotional responses;
Provides ongoing assessment of patient and family needs and responses to teaching;
Observes, documents and reports changes in the patient's condition and response to interventions/treatment to the interdisciplinary care team and Clinical Manager;
Participates in the discharge planning process;
Participates as a member of the interdisciplinary care team in care coordination activities and acts as a resource to other health team members in the identification and resolution of patient needs;
Able to supervise/instruct the performance of the Social Work Assistant (BSW/LSW) to assure that all medical social services are provided to patients in compliance with company, government and professional standards as applicable;
Maintains and submits documentation timely per company policy including any case conferences, patient/physician community contacts, visit reports progress notes.