To provide services to The Christ Hospital patients and families by assessing psychosocial needs and implementing a discharge plan of care to assure continuity of the patient's care.
Provides psychosocial interventions, advocacy and linkage with community resources.
KNOWLEDGE AND SKILLS:
• Exceptional skill interviewing patients and families in crisis and individuals with a wide range of physical and emotional problems. • Ability to prioritize many simultaneous demands. • Medical and psychiatric competence including knowledge of health policy, regulations, and legislation and community resources. • Self-awareness, professionalism, and good judgment in dealing with emotional and confidential issues. • Excellent verbal and written communication. • Skill in social work assessment and treatment modalities necessary to assess and treat individuals, families and groups. • Ability to integrate social work philosophy and ethics into professional practice.
EDUCATION:
• Master's degree in social work (MSW) required. • LSW/LISW required.
YEARS OF EXPERIENCE:
• 2 years clinical experience in hospital, long-term care or hospice setting preferred.
LICENSES & CERTIFICATIONS:
• Assure ongoing licensure through the State of Ohio Counselor, Social Worker, and Marriage and Family Therapist Board
ASSESSMENT/SCREENING
• Assess patients' evolving medical situation from a psychosocial framework, including functional status, goals of care, and community support needs as it relates to discharge planning • Assess family structure, dynamics, and decision-making preferences, including identification of a surrogate decision maker if needed • Assess patient/family environmental risk factors, patient/family/community support systems, age-related/developmental issues, financial barriers, health literacy, chemical dependency/mental health, Social Determinants of Health needs, and any risk of abuse/neglect/financial exploitation/intimate partner violence • Assess for risk of readmission, putting into place a coordinated plan for outpatient follow up
DOCUMENTATION
• Documents in Discharge Planning progress notes a clear, concise, objective psychosocial assessment, treatment plan, and progress of social work intervention and outcomes in compliance with regulatory standards and department standards for timeliness. • Documents appropriately in the Social Work module for data tracking purposes
DISCHARGE PLAN IMPLEMENTATION/CARE COORDINATION
• Develop a plan of intervention, which is integrated with the interdisciplinary treatment team to establish continuum of care in congruence with ethical and legal considerations. • Implements plan of care: • Provide psychosocial counseling and other therapeutic interventions for patient/family • Provide crisis management for patient/family • Facilitate healthcare decision making and resolution of discharge planning issues • Provide psychosocial intervention for: neglect/abuse/intimate partner violence/human trafficking; adjustment to illness; bereavement and mental health; substance abuse; non-compliance, and other psychosocial barriers to diagnosis and treatment • Mandated reporting to local/state agencies as required by law - Adult Protective/Child Protective Services, law enforcement • Maximize health status and minimize length of stay and appropriate utilization of hospital resources • Provide referral and linkage to health care and community resources based upon Social Determinants of Health screening needs • Facilitate extended care facility placement and hospital to hospital transfer • Facilitate home care, hospice care, and durable medical equipment arrangements • Advocate, mediate and negotiate a cohesive plan for maintaining or improving social supports and patient safety • Coordinate patient's discharge plan with outpatient counterparts - TCHMA SW, insurance case managers, community mental health/substance abuse case managers - to aid in readmission prevention
CONSULTATION/EDUCATION/COLLABORATION
• Attend unit specific interdisciplinary rounds daily • Collaborate with interdisciplinary team to enhance quality of care and efficiency. • Maintain a positive working relationship with healthcare team and community agencies and services. • Provide extensive education to patient/family in areas of insurance benefits, and capacity of community resources to meet patient needs • Participate in interdisciplinary patient care rounds, case conferences and family conferences for purpose of appropriate length of stay discharge planning. • Assist interdisciplinary team in understanding significant social and emotional factors related to illness. • Identify barriers in service delivery systems and advocate for change. • Provide education to interdisciplinary team, residents, students, other disciplines and community agencies • Evaluate patient outcomes and participate in process improvement.
CONTRIBUTIONS TO THE SOCIAL WORK DEPARTMENT
• Provide leadership and perform delegated management responsibilities. • Provide clinical supervision to peers, Bachelor degree staff, and students. • Provide mandatory and/or voluntary cross coverage when needed. • Participate in orientation of new staff. • Generate and support ideas to improve Social Work Department service delivery systems. • Identify complex clinical cases and seek supervision when appropriate
OTHER SERVICE-SPECIFIC DUTIES
• Assess patients' evolving medical situation from a psychosocial framework, including functional status, goals of care, and community support needs as it relates to discharge planning • Assess family structure, dynamics, and decision-making preferences, including identification of a surrogate decision maker if needed • Assess patient/family environmental risk factors, patient/family/community support systems, age-related/developmental issues, financial barriers, health literacy, chemical dependency/mental health, Social Determinants of Health needs, and any risk of abuse/neglect/financial exploitation/intimate partner violence • Assess for risk of readmission, putting into place a coordinated plan for outpatient follow up • Documents in Discharge Planning progress notes a clear, concise, objective psychosocial assessment, treatment plan, and progress of social work intervention and outcomes in compliance with regulatory standards and department standards for timeliness. • Documents appropriately in the Social Work module for data tracking purposes • Develop a plan of intervention, which is integrated with the interdisciplinary treatment team to establish continuum of care in congruence with ethical and legal considerations. • Implements plan of care: • Provide psychosocial counseling and other therapeutic interventions for patient/family • Provide crisis management for patient/family • Facilitate healthcare decision making and resolution of discharge planning issues • Provide psychosocial intervention for: neglect/abuse/intimate partner violence/human trafficking; adjustment to illness; bereavement and mental health; substance abuse; non-compliance, and other psychosocial barriers to diagnosis and treatment • Mandated reporting to local/state agencies as required by law - Adult Protective/Child Protective Services, law enforcement • Maximize health status and minimize length of stay and appropriate utilization of hospital resources • Provide referral and linkage to health care and community resources based upon Social Determinants of Health screening needs • Facilitate extended care facility placement and hospital to hospital transfer • Facilitate home care, hospice care, and durable medical equipment arrangements • Advocate, mediate and negotiate a cohesive plan for maintaining or improving social supports and patient safety • Coordinate patient's discharge plan with outpatient counterparts - TCHMA SW, insurance case managers, community mental health/substance abuse case managers - to aid in readmission prevention