Social Wkr MSW

Job Summary

The Social Worker MSW provides social work intervention, and proactive discharge planning support to patients and their families. They conduct thorough chart reviews, participate in interdisciplinary team meetings, and collaborate with post-acute care providers to ensure timely patient transitions.

Job Description

• Completes thorough chart review upon referral and throughout patient's stay.
• Attends Bed Huddles and Care Conferences daily to promote throughput activities.
• Provides information to Care Coordinator and Charge Nurse related to pending and confirmed discharges.
• Participates in ongoing communication with physician and interdisciplinary team to develop a collaborative relationship aimed at improving clinical treatment goals and appropriate and timely discharge for the patient.
• Proactively educates patients upon referral about advance directives, options for post-acute services and community resources available to them at discharge.
• Completes proactive initial and ongoing psychosocial assessments that holistically assess the patient for potential complex post-acute needs.
• Identifies hospital and community based resources which will meet patient/family needs and provides referrals and advocacy in obtaining services.
• Maintains active interaction with the patient/family throughout the treatment/discharge planning process in efforts to keep them apprised of discharge planning activities.
• Proactively makes appropriate referrals to internal and post-acute service providers to ensure continuity of care during and post hospitalization.
• Provides expertise to the team in developing treatment and discharge planning strategies for frequently admitted patients.
• Aids in the procurement of services and serves as an advocate on behalf of patient/family for scarce resources.
• Maintains high team standards by addressing coordination problems within the functioning of the healthcare team.
• Identifies and escalates any issues that relate to LOS/Throughput/Readmission management.
• Provides education regarding post-acute services (LTACH, acute rehabilitation, nursing facility, hospice, etc.) to patients, families, and hospital staff.

Education, Credentials, Licenses

• Graduate of an accredited masters' school of social work (MSW).
• Licensed as a Certified Social Worker (CSW) to practice social work in the state where work is being performed.
• Mets contact hour requirements for licensure, including all state required courses.

Specialized Knowledge

• Knowledge of psychosocial issues re: health related problems and post-acute care needs.
• Excellent communication skills and the ability to coordinate care well with an interdisciplinary team.