Social Worker Msw

About the Role

Ensures collaboration among multiple parties—including the patient, family, and the multi-disciplinary team (internal and external stakeholders, which may include the payer)—to facilitate and coordinate services specific to the patient’s needs during an episode of care and/or post-hospitalization. All case manager activities will be client-centric, performed proactively, and require ongoing assessment of needs, evaluation of resources, knowledge of associated costs, and education as indicated. The case manager is responsible for presenting options in an unbiased fashion to all involved parties while complying with HIPAA. Empowerment of the patient or healthcare proxy is expected to enable informed decisions regarding continued care needs. Advocacy and education are central to all activities, with the goal of achieving the best clinical outcomes through evidence-based practice.

Responsibilities

• Discharge Planning:
  • Conduct ongoing evaluation and re-evaluation of the patient’s needs daily or as indicated through interviews and chart reviews. Discharge planning begins at admission, with a tentative plan documented in the medical record within 24–48 hours.
  • Assess current and prior functioning, psycho-social dynamics, and support systems to develop a discharge plan in collaboration with the multi-disciplinary team, patient, and/or family.
  • Identify and address barriers to facilitate a smooth transition to the next level of care, including reviewing prior plans of care to prevent readmissions.
  • Review insurance benefits to ensure appropriate next-level care services, address co-pays/deductibles, and identify cost-related barriers to care.
  • Determine patient needs and resources within 24 hours of admission (or up to 48 hours in extenuating circumstances) and initiate the discharge planning process.
  • Consider patient and family healthcare literacy, education, and socio-economic status to ensure understandable and usable information is provided.
  • Coordinate and collaborate with the patient or decision-maker to provide information on financial resources, insurance limitations, and tentative discharge plans.
  • Familiarize the patient with the case manager’s role, hospitalization expectations, and potential care options (e.g., rehabilitation, nursing home, hospice, home care, community resources).
  • Provide a regulated "options" list of providers for the patient or healthcare proxy to choose from, expediting next-level care decisions.
  • Facilitate a collaborative environment with internal and external stakeholders (e.g., physicians, therapists, nurses, payers, community resources) to achieve the best outcome for the patient.
  • Advocate for patients unable to advocate for themselves, including mediation with the multi-disciplinary team or family.
  • Serve as a resource to resolve obstacles impeding high-quality, cost-effective care.
  • Coordinate post-hospitalization care, including discussions with primary care physicians or referrals to community resources (e.g., WIC, food stamps, HRSA).
  • Delegate discharge needs to healthcare team members as appropriate (e.g., education, completion of forms).
  • Coordinate plans for post-discharge care with a focus on age-specific or special population needs.
  • Complete requisite documentation in Allscripts and Meditech regarding discharge plans, discussions, and compliance with regulatory guidelines.
  • Participate in multidisciplinary collaboration for treatment plan development and secure authorization for additional patient services as required.
  • Verify insurance benefits for post-discharge care planning.
• Implementation and Facilitation of Care:
  • Act proactively to address real and potential issues in the development and implementation of the plan of care.
  • Document activities and discussions in the patient’s medical record, including outreach to external stakeholders (e.g., primary care providers) to overcome barriers to care.
  • Verify insurance benefits and secure authorizations from payers as indicated.
  • Facilitate necessary community resources and advocate for the patient’s ability to safely maintain themselves in the community.
  • Act as a mediator between physicians/consultants and families during conflicts or changes in patient status.
  • Identify potential barriers to a safe discharge during the initial assessment and re-evaluate the discharge plan daily, documenting in Allscripts and Meditech at least every other day.
  • Review current and past records to identify contributing factors to the patient’s illness or re-hospitalization.
  • Complete due diligence to identify additional assessments beyond the initial evaluation.
• Patient Advocacy and Education:
  • Respect and support the patient’s right to self-determination and freedom of choice.
  • Objectively present all care options, risks, benefits, and information to assist the patient or healthcare proxy in informed decision-making.
  • Maintain collegial and collaborative relationships throughout the care continuum.
  • Provide outreach to community providers as needed to ensure optimal patient outcomes.
  • Proactively consult and collaborate with internal and external stakeholders (e.g., during rounds, phone calls to practitioners/payers, or requesting consults with disciplines like physical therapy or psychiatry).
  • Document all activities and efforts to ensure a safe discharge, including patient/healthcare proxy choices, referrals, and final dispositions.
  • Respond to requests for consults and educational materials (e.g., elder law, advance directives) within one working day, per department standards.
  • Identify patients who may lack the capacity to make informed decisions and request evaluations for capacity when necessary. Consult with management and Risk Management as required.
  • Assist with guardianship issues if lack of capacity is confirmed.
• Data Collection and Compliance:
  • Participate in collecting information for quality improvement activities and risk management, reporting through appropriate committee structures.
  • Maintain knowledge of current case management theory, practice, quality initiatives, and regulatory requirements.
  • Stay informed about clinical practice guideline development, utilization, and measurement.
  • Participate in the prioritization and development of practice guidelines and committees focused on improving patient care and outcomes.
  • Monitor care practices in relation to accepted standards at Doylestown Hospital and regulatory entities (state and federal).
  • Identify and act on variances, including notifying supervisors as needed.
  • Collect and report information on quality improvement activities and risk issues through appropriate channels.
• Behavioral Expectations:
  • Exhibit consistent professional conduct in interactions with patients, families, medical staff, payers, and peers while respecting HIPAA requirements.
  • Take ownership of errors and implement immediate corrective actions when indicated.
  • Maintain high standards of professional conduct and demonstrate respect for medical staff, administration, colleagues, customers, and self.
  • Facilitate open communication and work to achieve positive, productive relationships with internal and external stakeholders.