Social Worker - In-Patient, Contingent

About the Role

Assists patients and families in coping with problems associated with severe and long-term illnesses. Conducts patient and family interviews, prepares psychosocial assessments, develops treatment plans, provides counseling and crisis intervention, and directs patients to designated community agencies and resources.

Responsible for coordinating the health care plan (including discharge plans from the acute setting and transitions of care to the post-acute care network) for assigned patient populations through the use of care plans, critical pathways, managed care, and collaboration with all members of the health care team. Evaluates care based upon quality, access, and cost-effectiveness. Maintains the continuum of care through the coordination and integration of all phases of patient care.

Provides consultation to patient treatment team members and participates in developing new patient care programs. In various settings, may provide individual, family, and/or group treatment as part of an interdisciplinary treatment plan. Provides quality patient care considering age-specific, developmental, cultural, and spiritual diversity, and/or other special needs or circumstances through competent clinical practices.

Responsibilities

• Functions as a member of the interdisciplinary care management team.
• Interviews patients and families to obtain psychosocial data.
• Evaluates and gathers data from the patient, family, outpatient supports, and other collateral sources regarding the plan of treatment and available resources, and develops an appropriate intervention plan.
• Provides a variety of direct services and clinical interventions to ensure continuity of care and help patients and families resolve socio-emotional problems associated with adjustment to illness, resource needs, mental health problems, and life events.
• Coordinates care of identified high-risk patient populations across the continuum, addressing psychosocial issues.
• In collaboration with the patient, family, and primary care provider, develops a plan to address and manage issues influencing healthcare utilization, including home services and facilitates transitions between care settings (e.g., hospital-to-hospital transfers, hospice, extended care facility, acute rehabilitation, and long-term care facility placement).
• Refers patients to designated community agencies or resources for financial assistance, counseling, mental health and substance abuse follow-up, and other support services.
• Conducts continuity of care planning, assessing needs and support services for home, and facilitates transitions to various care settings.
• Assesses, develops, and implements continuing care plans based on patient’s health self-care, knowledge, and/or social support system deficits.
• Conducts ongoing assessment and interdisciplinary collaboration regarding continuing care needs through the continuum.
• Applies expertise regarding service provider criteria, insurance coverage, and patient needs.
• Collaborates with the interdisciplinary team regarding patient progress toward expected outcomes and revisions to the plan of care.
• Initiates referrals to other providers and disciplines as indicated.
• Refers to skilled home care, durable medical equipment vendors, and other appropriate referral sources to assist the patient in achieving a safe, optimal continuing care plan.
• Collaborates with patient/family to ensure appropriate continuity of care arrangements and agency/vendor coordination.
• Provides ongoing assessment of educational needs of patient/family in collaboration with interdisciplinary staff and develops appropriate interventions.
• Demonstrates ability to make appropriate and useful changes in the patient’s treatment plan when problems persist and recognizes when discharge and/or transfer of care is in the best interest of the patient.
• Advocates, educates, and facilitates resolution of patient rights, ethical, and legal issues such as advance directives, end-of-life decisions, and guardianship.
• Systematically identifies and addresses barriers and fragmentation of care while proactively and collaboratively problem-solving to find solutions.
• Documents social work assessment data and progress notes for each patient, including the nature of psycho-social concerns, patient and family supports and needs, and intervention plans in accordance with department documentation standards.
• Provides consultation to other patient treatment team members regarding socio-emotional factors that affect the patient’s condition, treatment plan, and recovery.
• Regularly communicates with other departmental and community agency personnel to coordinate social work functions and other services, exchange patient information, and ensure continuity of care.
• Utilizes pertinent population data to identify trends and potential areas of targeted intervention. Uses metrics to establish measurable goals and monitor outcomes.
• Uses professional expertise to advance policies and practices that improve access to care, ensure timely follow-up, and support the delivery of evidence-based clinical management.
• In conjunction with identified leadership, develops, implements, and monitors clinical (and non-clinical) quality improvement processes.
• Regularly prepares and presents written reports that track, monitor, and measure outcomes of interventions to address patient/population needs and identify and remove barriers.
• Provides social work leadership in related committees, task forces, and workgroups with a focus on improved health outcomes for the populations served.
• Serves as a change-agent and resource to foster adoption of process/service/system improvement initiatives at various points of service.
• Serves in an advisory role for social policies in community development programs.
• Understands legal issues affecting treatment, including but not limited to child custody, divorce laws, child/adult abuse, duty to warn, recipient rights policies and procedures, alternative treatment orders (ATO’s), and the commitment of inpatient hospitalization.
• Maintains knowledge of current trends and developments in the field.
• Assumes responsibility for performance of job duties in the safest possible manner, ensuring personal safety and that of co-workers, and reports all preventable hazards and unsafe practices immediately to management.
• Reports all preventable hazards and unsafe practices, including near misses and actual errors, either to management or using the anonymous reporting system.
• Attends and participates in departmental, health system, and community committees and meetings as necessary.
• When working in Complex Social Work, provides care coordination, education, transition management, and outreach services to high-risk or high-utilizer patients in the post-acute care space.
• When working in Complex Social Work, acts as a liaison between inpatient and outpatient care settings to ensure continuity of care and adherence to the established plan of care for each patient.

Requirements

• Master’s Degree in Social Work from an accredited graduate school.
• Current State of Michigan Master’s Degree Social Work License (or Limited License MSW). LLMSWs are required to obtain their LMSW within 2 years of employment.
• Six to twelve months of related experience preferred.

Skills

• Interpersonal skills necessary to obtain information, provide counseling, and interact effectively with patients, families, and colleagues.
• Analytic skills necessary to assess patients’ needs, develop associated discharge planning, and provide sound advice and guidance.
• Ability to concentrate and pay close attention to detail for up to 90% of work time.
• Mobility to move between nursing units, outpatient settings, and in/out of patient rooms and offices.
• Demonstrates successful and progressive leadership and initiative.
• Demonstrates consistently high levels of clinical competence with the ability to provide clinical interventions at the individual, family, group, system, and community levels.
• Ability to function effectively within a multi-disciplinary team.
• Demonstrated ability to successfully provide quality patient care considering age-specific, developmental, and cultural needs.