Social Worker - Inpatient

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.

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, then develops an appropriate intervention plan.
• Provides 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.
• Collaborates with patients, families, and primary care providers to develop plans addressing healthcare utilization, including home services and facilitating transfers to hospice, extended care, acute rehabilitation, and long-term care facilities.
• Refers patients to community agencies or resources for financial assistance, counseling, mental health, substance abuse follow-up, and other support services.
• Conducts continuity of care planning, assessing needs and support services for home, and facilitates hospital-to-hospital transfers and placements.
• Assesses, develops, and implements continuing care plans based on patient health self-care, knowledge, and social support system deficits.
• Collaborates with the interdisciplinary team regarding patient progress 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 sources to assist patients in achieving safe, optimal continuing care plans.
• Collaborates with patients and families to ensure appropriate continuity of care arrangements.
• Provides ongoing assessment of educational needs of patients and families in collaboration with interdisciplinary staff and develops appropriate interventions.
• 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 problem-solving to find solutions.
• Documents social work assessment data and progress notes for each patient, including psycho-social concerns, supports, needs, and intervention plans.
• Provides consultation to other patient treatment team members regarding socio-emotional factors affecting patient conditions, treatment plans, and recovery.
• Communicates regularly with other departmental and community agency personnel to coordinate social work functions and ensure continuity of care.
• Uses pertinent population data to identify trends and potential areas of targeted intervention, establishing measurable goals and monitoring outcomes.
• Advances policies and practices that improve access to care, ensure timely follow-up, and support evidence-based clinical management.
• Develops, implements, and monitors clinical and non-clinical quality improvement processes in conjunction with leadership.
• Prepares and presents written reports tracking, monitoring, and measuring outcomes of interventions to address patient and population needs.
• Provides leadership in related committees, task forces, and workgroups focused on improved health outcomes.
• Serves as a change-agent and resource to foster adoption of process and system improvement initiatives.
• Serves in an advisory role for social policies in community development programs.
• Maintains knowledge of legal issues affecting treatment, including child custody, divorce laws, abuse, duty to warn, recipient rights, and commitment procedures.
• Stays updated on current trends and developments in the field.
• Performs job duties safely, reporting hazards and unsafe practices to management.
• When working in Complex Social Work, provides care coordination, education, transition management, and outreach services to high-risk or high-utilizer patients in post-acute care.
• Acts as a liaison between inpatient and outpatient care settings to ensure continuity of care and adherence to established plans.

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 as prescribed by the state licensing board.

Skills

• Interpersonal skills to obtain information, provide counseling, and interact effectively with patients, families, and colleagues.
• Analytic skills to assess patient needs, develop discharge plans, 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 patient rooms.
• Demonstrated leadership and initiative.
• High levels of clinical competence in providing interventions at individual, family, group, system, and community levels.
• Ability to function effectively within a multi-disciplinary team.
• Demonstrated ability to provide quality patient care considering age-specific, developmental, and cultural needs.