Social Work Staff - Care Facility And Utilization Management

• Works collaboratively with Case Management and the care team to evaluate psychosocial needs and to develop timely and patient-centered discharge plans.

• Key focus - low- and moderate-risk patients.

• Demonstrates the knowledge and skills necessary to provide interventions that are appropriate and individualized to the patients' needs.

• Demonstrates skills necessary to assess patients' needs for continuum of care issues and effective transition from hospital for both patient and his/her support system.

• Participates in multidisciplinary rounding process as requested.

• Exercises a substantial degree of professional judgment, recognizing deviation from the usual patient/family functioning, anticipating problems, and taking measures to maximize patient's successful discharge.

• Assists with assessments of discharge needs for new patients, as well as assessment and problem-resolution for patients who return to the hospital within 24 hours and/or 30 days of discharge.

• Evaluates patients/family needs and identifies problems related to compliance with medical care, being alert for signs of abuse and neglect, exploitation, and alcohol and substance misuse concerns.

• Coordinates services as appropriate including nursing home placements and returns, medication assistance, referrals to home health / medical equipment / homemaker services, transportation needs, and/or communicating with nursing homes regarding hospitalized residents progress. Per discharge needs assessment.

• Communicates daily with members of the interdisciplinary team to identify priorities and plan interventions accordingly.

• Leads the discharge planning process by initiating services needed for efficient discharge planning and reduction in length of stay.

• Provides social service consult by referral and follow-up as needed.

• Communicates with interdisciplinary team regarding identified needs and/or barriers and discharge plans daily.

• Communicates completely and frequently with patients/families when developing a discharge plan.

• Assists with multidisciplinary care conferences as necessary.

• Demonstrates the ability to mulch-task and implement time-management skills efficiently.

• Demonstrates accountability for personal and professional standards and competency in accordance with the hospital as well as their profession's ethical guidelines and standards.

• Participates in the orientation program for new staff, volunteers, and students as assigned.

• Serves as a resource of broad knowledge with regards to hospital and community resources related to emotional and financial support for patients and/or families, collaborating with Risk Management personnel to address related issues as needed.

• Acts as a resource, consultant, and liaison for the interdisciplinary team and patients, their support system, and the community.

• Advocates for patient needs within hospital and community to ensure patients have education and/or access to services needed for successful hospital discharges and reduction in potentially avoidable hospital readmissions.

• Acts as an advocate for the patient and their support system with hospital and community social and financial resources to ensure patient needs are met.

• Provides emotional support to patients and their support system to assist them in mentally and emotionally adjusting to their change in health status.

• Facilitates guardianship proceedings, in collaboration with risk management, when warranted.

• Assists with identification of under- and over-utilization of services.

• Assists in identification of barriers and problem-resolution for complex patient populations.

• Possesses real-time knowledge of updated community and hospital resources.

• Assists in counseling on Advanced Directives as appropriate.

• Assists with documentation in the EMR.* Documents all Discharge Planning components accurately in EMR.* Assists with documentation in EMR to support quality initiatives.

• Assists with audits for medical necessity documents as request

Provide psychosocial assessment, individual and family counseling and support, care planning, case management, and community education, outreach and referral services to clients and their families and/or caregivers.