Assists patients and families in coping with problems associated with severe and long-term illnesses. Conducts patient and family interviews, prepares psychosocial assessments, develops treatment plans, provides counseling and crisis intervention, and directs patients to designated community agencies and resources. Responsible for coordinating the health care plan (including discharge plans from the acute setting and transitions of care to the post-acute care network) for assigned patient populations through the use of care plans, critical pathways, managed care and collaboration with all members of the health care team. Evaluates care based upon quality, access, and cost-effectiveness. Maintains the continuum of care through the coordination and integration of all phases of patient care. Provides consultation to patient treatment team members and participates in developing new patient care programs. In various SJMH settings, may provide individual, family, and/or group treatment as part of interdisciplinary treatment plan. Provides quality patient care considering age specific, developmental, cultural, and spiritual, diversity, and/or other special needs or circumstances through competent clinical practices.
Functions as a member of the interdisciplinary care management team.
Interviews patients and families to obtain psychosocial data. Evaluates and gather data from the patient, family, outpatient supports and other collateral sources (including the primary care provider) regarding plan of treatment and available resources, and develops an appropriate intervention plan.
Provides a variety of direct services and clinical interventions in order to provide continuity of care and to help patients and families resolve socio-emotional problems associated with adjustment to illness, resource needs, mental health problems and a variety of life events and transitions.
Coordinates care of identified high-risk patient population across continuum, among others addressing psychosocial issues. In collaboration with patient, family a primary care provider, develops plan to address and manage issues which influence health care utilization including services for home as well as facilitates hospital-to-hospital transfers, hospice, extended care facility, acute rehabilitation and long-term care facility placement.
Refers patients to designated community agencies or resources for financial assistance, counseling, mental health and substance abuse follow up, and other support services.
Conducts continuity of care planning for assessing needs and support services for home, as well as facilitates hospital to hospital transfers, hospice, extended care facility, acute rehabilitation and long-term care facility placement.
Accountability for discharge planning/continuing care needs for assigned populations, including Assesses, develops, and implements continuing care plans based on identification of patient's health self-care, knowledge, and /or social support system deficits. Conducts ongoing assessment and interdisciplinary collaboration regarding continuing care needs through the continuum. Applies expertise regarding Service Provider Criteria, Insurance Coverage criteria and identification of patient needs. Collaborates with interdisciplinary team regarding patient progress towards expected outcome and revisions to plan of care. Initiates referrals to other providers and disciplines (i.e. Infectious Diseases, Risk Management) as indicated. Refers to Skilled Home Care, Durable Medical Equipment vendors and other appropriate referral sources to assist patient in achieving a safe, optimal continuing care plan. Collaborates with patient/family to ensure appropriate continuity of care arrangements and agency/vendor.
Provides ongoing assessment of educational needs of patient/family in collaboration with interdisciplinary staff and develops appropriate interventions and programs in response and maintains good working relationships with community resources. Demonstrates ability to make appropriate and useful changes in the patient's treatment plan when problems persist and recognizes when discharge and/or transfer of care is in the best interest of the patient.
Advocates, educates, and facilitates resolution of patient rights, ethical and legal issues such as advance directives, end of life decisions, guardianship, etc.
Systematically identifies and addresses barriers and fragmentation of care while proactively/collaboratively problem solving to find solutions.
Documents social work assessment data and progress notes for each patient including nature of psycho-social concerns, patient and family supports and needs, and intervention plan in accordance with department documentation standards.
Provides consultation to other patient treatment team members regarding socio-emotional factors that affect patient's condition, treatment plan and recovery.
Regularly communicates with other departmental and community agency personnel to coordinate social work functions and other services, exchange patient information, and ensure continuity of care.
Utilizes pertinent population data to identify trends, potential areas of targeted intervention. Uses metrics to establish measurable goals and monitor outcomes. Uses professional expertise to advance policies and practices that improve access to care, ensure timely follow-up care and supports the delivery of evidence-based clinical management.
In conjunction with identified leadership, develops, implements and monitors clinical (and non-clinical) quality improvement processes. Regularly prepares and presents written reports that track, monitor and measure outcomes of interventions to address patient/population needs and identify and remove barriers.
Provides Social Worker leadership in related committees, task forces and work groups with a focus on improved health outcomes for the populations served. Serves as a change-agent and resource to foster adoption of process/service/system improvement initiatives at various points of services. Serves as an advisory role for social policies in community development programs.
Understands legal issues that affect treatment, including but not limited to: child custody, divorce laws, child/adult abuse, duty to warn, recipient rights policies and procedures, alternative treatment orders (ATO's), and the commitment of inpatient hospitalization.
Maintains knowledge of current trends and developments in the field.
Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of co-workers, and to report all preventable hazards and unsafe practices immediately to management. Reports all preventable hazards and unsafe practices including near misses and actual errors either to management or using the SJMHS anonymous reporting system (VOICE).
Attends and participates in departmental, Health System, and community committees and meetings as necessary.
When working on the Complex Social Work; provides care coordination, education, transition management, and outreach services to high-risk or high utilizer patients in the post-acute care space.
When working on the Complex Social Work; acts as liaison between inpatient and outpatient care settings to ensure continuity of care throughout each site of care, and to ensure communication about and adherence to the established plan of care for each patient.
