Job Details

POSITION DESCRIPTION:

The Post-Acute Transitional Social Worker is an integral member of the ambulatory care team.  This position is responsible for addressing social needs for patients in post-acute settings including, but not limited to, skilled nursing facilities, long-term care hospitals, inpatient rehabilitation facilities, home health agencies and patients’ homes in multiple counties in Southeast Michigan. Specific focus on patients requiring care in a Skilled Nursing Facility (SNF), the Post-Acute Transitional Social Worker duties will include on-site assessment and collaboration with SNF social workers, patient and family to ensure a safe discharge to next level of care for patients.  The Post-Acute Social Worker will do home visits as needed to assess needs in the home, caregiver support and community resources.   The social worker, in collaboration with the Post-Acute Transitional Care Manager, will communicate with the primary care team to ensure a seamless handoff to longitudinal care management, when appropriate.  

ESSENTIAL JOB FUNCTIONS:

1. Obtains a thorough assessment of the patient that includes current clinical status, family and caregiver support, social determinants of health, and patient and caregiver goals for discharge.
2. Assesses the family's knowledge base, expectations and the ability for a family member to act as the primary caregiver, if appropriate.
3. Assists the individual, the family and team in identifying the variables that may influence the accomplishment of goals.
4. Supports the development of a realistic and safe discharge plan with the care team, Post-Acute Transitional Care Manager and patient/family.
5. Develops a strong team-oriented relationship with the rehabilitation team within the post-acute setting to ensure the patient’s plan of care is being carried out in a timely manner.
6. Participates in conferences that provide ongoing evaluation of interprofessional dynamics, goal attainment and treatment plan revision.
7. Responsible for supporting the patient care plan in collaboration with the patient and interdisciplinary care team which includes the treatment plan, disposition, progress, anticipated needs and expected length of stay. 
8. Promotes effective communication among the healthcare team members, including the patient, family, interdisciplinary team, case managers and primary care physician.
9. Serves as a liaison between the patient, physician, care team and the discharge planner by coordinating, monitoring, and communicating the patient’s goals and progress, and assisting with coordination to the next level of care.
10. Facilitates and collaborates with the healthcare team for timely discharge planning to an alternate level of care or return to the individual’s previous level of care.

1. Coordinates appropriate resources and supportive services to meet the patient’s needs at the time of transition to next level of care, based on collaboration with the healthcare team recommendations.
2. Once patient transitions to next level of care, to ensure a smooth transition, performs home visits as appropriate working with the Post-Acute Transitional Care Manager to determine priority.  
3. Addresses patient ethical and legal issues such as advanced directives, end of life decisions and guardianship.
4. Refers patients to appropriate community agencies to access services to meet patient’s psycho-social needs. 
5. Provides verbal and written education to the individual and family regarding community resources and supportive services.
6. Other duties as assigned.