Social Worker - Population Health Care Management - Day

Essential Functions:

• Interviews patients and family members to obtain information about home environment, family relationships, health history, and patient's personality traits.
• Evaluates data gathered in terms of the medical plan of treatment, available social service programs, and plans a pertinent therapy program that will provide each patient with maximum benefit.
• Assists patients and families to understand, accept, and follow medical recommendations.
• Utilizes resources to help patient resume life in the community or to learn to live with the disability.
• Interprets nature of illness and prescribed course of treatment to patients and families. Communicates family issues to other staff members.
• Participates in planning conferences to identify significant social, economic and emotional factors related to the health problem and assist in formulating the plans of care for specific patients.
• Provides social work consultation to the staff to enable them to assess the significant social, economic and emotional factors related to the health problem.
• Advises the staff on community resources available to meet patient needs and assists in making appropriate referrals.
• Assists in the orientation of new staff or continuing education of existing staff as requested.
• Assists in identifying staff development needs related to family dynamics or social-economic factors.
• Reviews and co-signs clinical progress notes written by BSW.
• Assists in developing discharge and post-hospital care plans.
• Collaborates with other hospital programs and community agencies with which patients and families are involved.
• Performs follow-up calls and/or checks with health care and related agencies used after patient discharge.
• Prepares and maintains required documentation on each case.
• Records the social service component of care on the patient's record, including the identified social problems and treatment plans that have been implemented.
• Submits clinical documentation and records in an accurate, legible and timely manner consistent with agency policy. Meets or exceeds established productivity.
• Actively seeks consultation or direction from management personnel as appropriate.
• Participates in staff development and in-service programs, as requested.
• Promotes a positive corporate image.
• IF ASSIGNED TO VNA: Under Physician's order, provides direct social casework services and home visits to individuals and families.
• IF ASSIGNED TO VNA: Maintains current knowledge on community resources and develops a referral network system.
• IF ASSIGNED TO VNA: Represents the VNA at community meetings as delegated by clinical management.

Common Expectations:

• Demonstrates knowledge of the principles of growth and development over the life span of the assigned patient population. Assesses and interprets patient age specific data and provides appropriate, age specific treatment. Provides direct patient care to assigned patient age group(s).
• Demonstrates a commitment to patient, visitor and staff by: complying with all applicable safety regulations; learning the impact of medical errors and methodology that will lead to reduction of errors; reporting actual and potential errors, as well as hazardous conditions; identifying opportunities to standardize processes and "error proof" systems that will lead to increased safety; and participating in safety education programs and root cause analyses as required.
• Maintains established policies and procedures, objectives, quality assessment, safety, environmental and infection control standards.
• Enhances professional growth and development through participation in educational programs, current literature, in-service meetings, and workshops.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
• Attends meetings as required.