Description
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Sanai Grace Hospital is committed to providing exceptional patient care in a supportive and collaborative environment. As a member of our team, you will have the opportunity to work with advanced technology and be part of a healthcare community dedicated to making a positive impact on the lives of our patients.
Benefit StatementAt Tenet Healthcare, we understand that our greatest asset is our dedicated team of professionals. That's why we offer more than a job - we provide a comprehensive benefit package that prioritizes your health, professional development, and work-life balance. The available plans and programs include:
- Medical, dental, vision, and life insurance
- 401(k) retirement savings plan with employer match
- Generous paid time off (PTO)
- Career development and continuing education opportunities
- Health savings accounts, healthcare C dependent flexible spending accounts
- Employee Assistance program, Employee discount program
- Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder C childcare, auto C home insurance.
Note: Eligibility for benefits may vary by location and is determined by employment status
Summary DescriptionThe 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
