Clinical Social Worker - MSW - Weekends

About the role

The Social Worker, Masters provides psychosocial assessment, care planning, and discharge support, collaborates with the care team and community resources, and ensures high-quality patient-centered services. The clinical social worker provides psychosocial assessments, interviews, and/or treatments and discharge planning to patients and families to assist them in coping with hospitalization, illness, diagnosis, and/or life situation. The social worker works collaboratively with other members of the health care team, community resources, regulatory agencies and third party payers in order to facilitate the transition of the patient through the organization while maintaining the highest quality of services possible. The social worker will adhere to the National Association of Social Work Code of Ethics. The clinical social worker utilizes critical thinking skills, advanced problem solving, therapeutic interventions and advanced care planning in the day to day functions.

Responsibilities

• Conducts a complete psychosocial assessment of the patient and family when services are initiated; for hospice, contact is made within 5 days of start of care.
• Formulates, develops, and implements a comprehensive treatment plan and/or plan of care utilizing appropriate social work interventions that may include short-term individual counseling, community resource planning, crisis intervention, and patient/caregiver education.
• Reviews and updates the interdisciplinary team (IDT) plan of care as often as necessary (at least every 14 days for Hospice) and contributes to the medical plan of treatment at recertification.
• Achieves documentation standards for quality, timeliness, and confidentiality of medical records in accordance with organizational and departmental defined policies and procedures; adheres to established productivity measures or departmental expectations.
• Ensures orders are in place for services, as necessary; reports changes in emotional, social, or financial condition of the patient or family to the provider.
• Maintains an extensive knowledge of benefit plans, regulatory guidelines and resources; acts as a consultant to hospice program staff as indicated; participates in the quality improvement reviews and evaluation of social work services.
• Remains current with social work and health care developments; seeks opportunities to enhance job related knowledge.
• Delivers or supervises the delivery of social work services to the patient or the patient's family; provides supervision, teaching and training for students, staff and other disciplines as indicated.
• Conducts abuse/neglect screening, suicide intervention, behavioral contracting, financial counseling, discharge planning, and/or guardianship processes as indicated.
• Leads advance care planning (ACP) and end of life discussions; assists with ACP document completion where needed; provides therapeutic interventions to achieve goals of care; establishes and maintains appropriate boundaries with patients/families.
• Provides psychosocial assessments of patients and families to identify emotional, social and environmental strengths and problems related to their preventative health management, diagnosis, illness, treatment, and/or life situation.
• Utilizes assessment and social work experience to plan and coordinate patient care; evaluates the process at appropriate intervals and modifies or changes the plan as necessary.
• Monitors utilization of healthcare resources such as ED, urgent care, admissions or frequent office visits; collaborates with team to address unnecessary utilization and plan for appropriate support to modify process behaviors.
• Arranges, secures, and coordinates assistance with unmet patient/family needs, to include social service, financial, and insurance applications and follow up, medications, DME, and transportation to/from clinic appointments.
• Refers patient or family to community resources to provide access to services such as financial assistance, legal aid, or housing; refers to DSS with suspected abuse or neglect of child or adult.
• Participates in care team pre- and post-visit case reviews and related meetings; collaborates with the health care team and/or care coordinator verbally or via chart entries related to the patient's progress toward reaching expected outcomes or about barriers to the plan; modifies treatment plans to comply with changes in client's status.
• Provides education and self-management strategies to patients and families around issues related to adaptation of the patient's health and addressing any contributing barriers to achieving goals.
• Provides supervision, teaching and training for students, staff and other disciplines on an as needed basis; attends department educational offerings and utilizes in ongoing practice.
• Facilitates an interdisciplinary approach to patient care; actively participates in interdisciplinary meetings sharing meaningful and profession-based assessments regarding progression of care.
• Provides feedback to the care team via verbal, electronic, and through ongoing documentation; maintains daily communication with Case Manager and Utilization Review including case reviews, morning touchpoints, and ongoing throughout the work day.
• Identifies and supports the range of emotions and coping styles of patients and families; establishes and maintains appropriate boundaries with patients/families.
• Participates in system and departmental performance improvement initiatives; adheres to productivity measures; successfully utilizes predictive analytics software to meet organizational/departmental initiatives and goals.
• Collects and analyzes relevant patient care and fiscal data; monitors length of stay for level of care appropriateness and need for continued stay; identifies and captures avoidable delays; escalates delays and opportunities internal to system and external.
• Complies with all departmental policies, procedures, and standards of practice.

Care Transitions

• Inpatient Rehab Facility
• Long-term Care
• Assisted Living Facility
• Skilled Nursing Facility
• Substance Abuse triggers: inter