Description
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DMC Sinai-Grace Hospital is DMC’s largest hospital, offering a comprehensive heart center, cancer care, gerontology, emergency medicine, obstetrics/gynecology and cosmetic services. Sinai-Grace’s joint replacement program features a revolutionary minimally invasive knee and hip replacement surgery that attracts patients from all over the country. Sinai-Grace operates more than 21 outpatient care sites and ambulatory surgery centers throughout Wayne and Oakland Counties and is one of 10 hospitals in the nation to be awarded a Robert Wood Johnson Foundation grant to help set the standards of cardiac care for hospitals and physicians throughout the nation.
Summary Description The Social Worker is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient's resources and right to self-determination. The individual in this position has overall responsibility for to assess the patient for transition needs including identifying and assessing patients at risk for readmission. Conducts complex psycho-social assessment and intervention to promote timely throughput, safe discharge and prevent avoidable readmissions. This position integrates national standards for case management scope of services including:
- Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
- Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care
- Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
- Education provided to physicians, patients, families and caregivers
This individual's responsibility will include the following activities: a) complex psycho-social transition planning assessment and reassessment and intervention, b) assistance with adoptions, abuse and neglect cases, including assessment, intervention and referral as appropriate to local, state and /or federal agencies, c) care coordination, d) implementation or oversight of implementation of the transition plan, e) leading and/or facilitating multi-disciplinary patient care conferences including Complex Case Review, f) making appropriate referrals to other departments, g ) communicating with patients and families about the plan of care, h) collaborating with physicians, office staff and ancillary departments, i) assuring patient education is completed to support post-acute needs , j) timely complete and concise documentation in Case Management system, k ) maintenance of accurate patient demographic and insurance information, l) and other duties as assigned.
POSITION SPECIFIC RESPONSIBILITIES: Transition Management - Completes comprehensive assessment within 24 hours of patient admission to identify and document the anticipated transition plan for patients
- Integrates key elements of patient assessment, patient choice and available resources to develop and implement a successful transition plan
- Completes Complex/Psycho-social assessment and plan for patients identified as high risk for readmission.
- Provides psycho-social assessment and intervention for patients identified with identified needs including behavioral health, lack of support systems, financial barriers, end of life, and/or medication adherence.
- May delegate the implementation of the transition plan to LVN/LPN or Assistant staff. And follows up to ensure the transition plan is completed timely and accurately
- Ensures all elements of the transition plan are implemented and communicated to the healthcare team, patient/family and post-acute providers
- Provides information to patients to make informed choices when community services per Tenet policy
- Completes Final Discharge Disposition Form Assessment for Medicare patients per Tenet policy
- Completes timely, complete and accurate documentation in the Tenet Case Management system to communicating information to the care team and provide documents needed in the patient record(40% daily, essential)
Care Coordination - Screens patients for factors that may affect the progression of care and intervenes as needed to promote timely and appropriate throughput
- Conducts assessments and stratifies patients at risk for readmission or in need of Case Management services
- Assists with adoption/abuse/neglect cases and reporting of appropriate cases to local, state and/or federal agencies
- Ensures the plan of care is consistent with patient choice and available resources
- Ensures patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of care
-Effectively collaborates with physicians, nurses, ancillary staff, payors, patients and families to achieve optimal outcomes(40% daily, essential).
Education - Ensures and provides education to patients, physicians and the healthcare team relevant to the safe and timely patient transit
