Major Responsibilities:

• Complex Discharge Planning based on assessment of patient and family needs, preferences and available resources in order to ensure a timely discharge and to provide appropriate linkage with post-discharge care providers( i.e. New/Resumptions SNF, LTAC, Rehab, Dialysis, Hospice, DME and Home Health etc. )
  • 5)Provides consultation to Case Managers when coordination with significant or intensive community resources is necessary to achieve desired treatment outcomes
  • 6)Uses knowledge of insurance benefits and coverage guidelines to maximize appropriate utilization or resources.
  • 1)Develops discharge plan in direct consultation with patient, family, physician, and health care team. Deals with families exhibiting complex family dynamics that impact directly on patient care and discharge.
  • 2)Manages complex cases/situations and intervenes with and advocates for patients and families as plan of care and discharge plan are developed.
  • 3)Educates patients and families regarding appropriate resources, access to services and third party requirements, and makes appropriate and timely referrals to address post-acute discharge needs.
  • 4)Educates patients and families regarding appropriate resources, access to services and third party requirements, and makes appropriate and timely referrals to address post-acute discharge needs.
• Psychosocial Assessment and Interventions on the basis of preliminary risk screening, assesses patients and family's psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope. Supportive counseling and clinical Social Work intervention for patients and families in acute emotional distress.
  • 1)Counsels patients and families regarding issues of loss, disability, separation, financial impact, and traumatic life style changes. Coaches families in developing coping mechanisms to support adaptation to changes.
  • 4)Utilizes crisis intervention techniques when indicated.
  • 2)Counsels and assists patients and families regarding Advanced Directives, end of life issues, and ethical issues that may arise.
  • 3)Interacts with appropriate agencies on issues of suspected abuse and neglect, domestic violence, guardianship, and other social/legal matters.
  • 5)Provides referrals to community-based support resources as appropriate.
• Accountable for site specific KRA goal achievement as it relates to Care Coordination across the continuum.
  • 1)Manages the progression of patients stay with the goal of optimizing the LOS and ensuring appropriateness of assigned Level of Care.
  • 2)Manages the patients care across the continuum to decrease unnecessary readmissions.
  • 3)Manages and coordinates patient care within an ACO environment to help facilitate patient outcomes through in network care coordination
• Maintenance of professional standards and responsibilities for his/her own professional practice according to accreditation, hospital, system, state and NASW Standards and Code of Ethics.
  • 1)Completes all required continuing education to maintain licensure and increase knowledge within area of practice specialty.
  • 2)Completes and utilizes all annual safety and competency training.
  • 3)Maintains up-to-date knowledge of community resources, legislation, and regulations impacting health care delivery and educating patients and families on these issues as appropriate.
• Functions as a member of the interdisciplinary team, sharing expertise to assist in the diagnostic and treatment planning process.
  • 1)Maintains effective communication and working relationships with members of the interdisciplinary team.
  • 2)Attends care conferences/unit huddles or other care planning meetings as per department policy.
  • 3)Partners with external agencies and facilities to provide continuity of care for patients and families.
  • 4)Documents all interventions and discharge plans to provide the health care team with accurate and up-to-date information regarding development/progress of the discharge plan and psychosocial interventions with responses.
• Completion of an assessment/history on all identified patients within appropriate time frames.
  • 1)Interviews patient and significant others to assess patient's psychosocial situation.
  • 2)Identifies patient and family preferences, needs and strengths, to foster for the patient and family empowerment and independence to make autonomous health care decisions and access needed services within the health care system.
  • 3)Formulates and documents a plan of intervention as a member of the interdisciplinary team in compliance with standards of care.
• Engages in Performance Improvement and patient safety initiatives.
  • 1)Identifies and communicates quality, risk, and patient safety issues to Care Management or other appropriate leadership.
  • 2)Accepts responsibility by participating in staff, department, or Organizational process improvement and safety initiatives.

Licensure:

• Social Worker, Clinical

Education/Experience Required:

• * Masters degree of Social Work from an accredited school

Knowledge, Skills & Abilities Required:

• * Has demonstrated time management, organization and documentation skills * Demonstrated understanding of medical terminology, developmental stages and psychosocial treatment * Demonstrated solid communication skills and collaboration with the interdisciplinary team
• * LSW or eligible (if eligible, must obtain within one year of employment)

Physicial Requirements and Working Conditions:

• * Ability to handle crisis situations * Weekend, holiday and evening coverage as per site requirements * Resiliency and flexibility to effectively work within a constantly changing health-care environment * Demonstrated problem-solving ability * Fast paced work environment with established time constraints * Ability to handle multiple tasks and complete work within short timeframes * May be exposed to hazardous materials and life threatening diseases * Knowledge of universal precautions * Is customer and service focused

Addendum: "VAD Supportive: As part of the multidisciplinary team, provides supportive care for the Ventricular Assist Device (VAD) patients with a high degree of skill and knowledge under their direct role. Educational requirements: The following educational requirements associated with this direct care role: Orientation: Completion of VAD introductory CBT. Continuing Education: Continuing education with an emphasis or focused on advanced heart failure therapies is to be completed every 6 months. This includes one VAD specific CBTs through Advocate ATMS or Industry Website CBT every 6 months. Attendance at an Advanced Heart Failure, Transplant or VAD Symposium may substitute for one of the CBT's. "

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.