Clin Social Wrkr IP/OP LCSW

About the Role

The Clinical Social Worker provides and coordinates psychosocial and behavioral services to her/his group of patients. She/he assesses, plans, implements and monitors a plan of care for her/his group of patients. This is done in collaboration with other members of the medical team, i.e. physicians, nurses, case managers, PT/OT staff, pharmacists. Works with the care team in a designated setting to identify, and, when possible, advocates for the patient; works to provide direct services, resources, and counseling that a patient/client needs to create a safe, effective and efficient transition/discharge from the hospital or clinic. Provides his/her expertise in a crisis intervention situation and assesses for potential abuse/neglect of vulnerable patients.

Responsibilities

• Contributes to the development of the multidisciplinary plan of care of his/her assigned patients, focusing on the identification of needs, and the progression of care, while assuring the quality and appropriateness of care.
  • Completes an assessment on those patients she/he is consulted on, and/or those patients identified through "screens" developed to flag high-risk patients.
  • Performs a comprehensive evaluation including social, behavioral, emotional, mental status, environmental and financial assessment in conjunction with the interdisciplinary team on identified/consulted cases.
  • Selects an appropriate therapeutic modality for use with a patient/client to facilitate positive coping/adjustment behaviors, enhance compliance with prescribed treatments, participation in discharge planning and acceptance of responsibility for follow through with the post treatment plan.
  • Develops post-discharge care plans based on a comprehensive patient evaluation that allow for a safe and effective discharge.
• Promotes optimal management of resources through regular and ongoing communication with the care team, and when appropriate, the utilization management staff.
  • Participates in the unit care coordination rounds to update the plan of care when needed.
  • Communicates regularly with the medical care team (physicians, nursing, PT/OT, Dietary, Respiratory, etc), to gather information from them on plans for the patient and provides information on resources available to them relative to discharge plans.
  • Plans for, participates in and in some cases leads patient/family care conferences to establish patient outcomes and evaluate patient care.
  • Works with the utilization management staff to assure that the patient is in the correct status and the requirements of the patient's insurance company.
• During the patients visit and/or stay in the hospital, conducts an ongoing assessment and identifies process delays impacting the timeliness of patient care.
  • Communicates with the care team to impact on the utilization of resources, and any delays in care.
  • Collects and reports variances and avoidable days to managers and places the information in the departments tracking system.
  • Escalates cases to a physician advisor or a manager if his/her attempts to move a case along are not being addressed.
• Facilitates an appropriate discharge for his/her patients in accordance with the patient's medical readiness and expected needs. Coordinates the discharge/transition of care for her/his patients to settings such as behavioral health facilities, hospice, home, substance abuse facilities etc.
  • Prepares the patient and/or family for discharge by providing an explanation of the plan and what the patient/family can expect.
  • The discharge is facilitated in accordance with regulatory requirements, patient/family choice, financial resources, and third party payor requirements.
  • Ensures a safe and effective handover to the next level of care by working closely with both hospital and clinic staff and external agency liaisons and care navigators.
• Provides clinical Social Work Services to patients, families and others in times of need.
  • Provides counseling services in reaction to illness, end of life care and disability issues.
  • Provides crisis intervention and stabilization in both emergent and urgent situations.
  • Leads the medical team in the management of all protective services cases; this includes child and adult protective services cases, identification of abuse/neglect, mental capacity, support systems and living situations.
  • Makes recommendations and referrals based on an assessment of the situation and within the constraints of professional licensure.
• Provides thorough and timely documentation in the medical record.
  • Documents findings, actions taken, and discharge arrangements made according to departmental guidelines and regulatory standards.
  • Prepares sufficient documentation to assure the efficient handoff of active cases per department policy.
  • Prepares reports and medical records for transfers, as required, and closes cases in electronic systems according to department guidelines.
• Maintains her/his own clinical competency, ethical standards and/or certification requirements.
  • Meets requirements for the job, i.e. My Training, Vaccinations, etc.
  • Maintains a knowledge of and adherence to hospital and departmental policy, and to the NASW Code of Ethics.
  • Maintains a knowledge of case management, utilization management and discharge planning requirements specified by federal, state and insurance guidelines.
  • Serves as an educational resource to the medical team and others regarding the availability of community resources and the discharge planning process.

Qualifications

Minimum Education and Experience Requirements: Master's degree in Social Work (MSW) required from an institution accredited by the Council on Social Work Education. Recent clinical experience applicable to the designated population served. Experience in a healthcare setting preferred.

Licensure/Certification/Registration: Valid LCSW in the State of Florida; professional certification in specialty area required.

Motor Vehicle Operator Designation: Employees in this position will not operate vehicles for an assigned business purpose.