Coordinates the care and services of select patients across the continuum of illness. Intervenes with patients who have complex psychosocial and discharge planning needs. Conducts a detailed psychosocial assessment, linkages with community resources and supportive counseling. Offers crisis interventions to patients and families with psychosocial needs. Facilitates transition of care for high risk patients facing barriers to care.
- Manages all aspects of discharge planning for assigned patients in order to ensure a timely discharge and provide appropriate connection with post-discharge care providers.
- Works with families exhibiting complex family dynamics.
- Communicates with interdisciplinary team regarding the discharge planning status of all patients that are referred.
- Educates patient, family and physician regarding post-acute options and addresses freedom of choice and financial concerns.
- Conducts initial and ongoing psychosocial assessment and interventions and makes treatment recommendations to engage patients and families in adherence to the treatment plan by reducing or eliminating the social, psychological, financial, behavioral and regulatory barriers to successful medical outcomes.
- Serves as a resource person to provide counseling and intervention related to treatment decisions and end-of-life issues.
- Advocates for patient and family by providing intervention in cases involving child abuse and neglect, domestic violence, elderly abuse, institutional abuse and sexual assault.
- Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the health care system and community.
- Meets core social work competencies and adheres to regulations.
- Remains current with regulations which impact the care of patients and regulatory compliance.
- Promotes individual, professional growth and development and meets mandatory and continuing education requirements.
- Supports department-based goals which contribute to the success of the organization.
- Serves as a preceptor, mentor, and resource to less experienced staff and represents the department on committees.
- Other duties as assigned.
- Master's Degree in Social Work or Masters of Science in Social Administration (MSSA).
- Current state licensure as a Social Worker.
- Eligible licensure includes LSW, LISW, LISW-S or PC.
- For Homecare and Hospice, eligible licensure includes LSW, LISW or LISW-S.
- Care Management Department requirement: Certification as a Case Manager within one year of eligibility from an approved professional organization. This Certification is not required for Homecare and Hospice Social Workers.
- Basic Life Support (BLS) through American Heart Association (AHA).
- For Homecare and Hospice field staff only: Valid Ohio Driver's license upon hire; per policy 8-175 thereafter.
- For Homecare and Hospice field staff only: Proof of automobile insurance coverage with $100,000/$300,000 coverage, upon hire; per policy 8-175 thereafter.
Complexity of Work:
- Requires critical thinking to use appropriate NASW Code of Ethics practices and complete assessments incorporating relevant biomedical, psychosocial and spiritual factors.
- Strong interpersonal, communication and negotiation skills required.
- Demonstrates patience, tact, critical thinking, problem solving, and deductive reasoning skills.
- Dependable, self directed and motivated self starter.
- Hospital Social Work experience preferred.
- For homecare and hospice, two years' experience required.
- Exposure and experience in pre-acute and post-acute care.
- Knowledge of community resources preferred.
- Excellent communication and negotiation skills necessary to work collaboratively with multidisciplinary teams for optimal outcomes.
- Demonstrated ability to work independently as well as with teams.
- Must be flexible, open-minded and adaptable to change.
- Requires full range of motion, manual and finger dexterity and eye-hand coordination.
- Requires standing and walking for extensive periods of time.
- Requires normal or corrected hearing and vision to normal range.
- Sedentary work exerting up to 10 pounds of force occasionally (Occasionally: active or condition exists up to 1/3 of the time) and /or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
- Sedentary work involves sitting most of the time.
- Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
Personal Protective Equipment:
- Follows standard precautions using personal protective equipment as required.