Social Worker - Transplant

The Social Worker creates optimal outcomes for the patient and family by managing complex psychosocial and economic co-morbidities. Through advanced practice skills mobilizes resources to reduce risk and serves as ambassador between hospital and community.

Provides social work services to patients and families to optimize their ability to benefit from treatment, cope with the realities of their medical condition, and participate in their care. Coordinates transitions of care for patients with high psychosocial needs. Develops and maintains current knowledge of and liaisons with local, state, and federal services that may provide education and resources to patients and families.

Supports the efforts of HIM and Patient Accounts by ensuring timely, accurate, and complete data entry in multiple information systems/data bases. Ensures understanding through collaboration with Care Manager and other interdisciplinary team members for review of multidisciplinary plan of care in patient chart (estimated LOS, tentative discharge date, assessed needs for discharge, and plan discussed with patient/family). Ensures attendance at Multidisciplinary Rounds or Huddles and reports on psychosocial status and its implication for transitions of care.

Monitors progress toward the goals of the social work plan of care and revises it in response to changes in patient needs and condition. Assesses any potential obstacles to successful reintegration into the community (clinical, social, support, home environment) and escalates through appropriate channels to resolution. Responsible for performing job duties in accordance with mission, vision and values of Tampa General Hospital.

Effectively communicates and collaborates with all members of the health care team to facilitate the episode of care so the patient receives services in a safe and timely manner, and the patient and family are provided all necessary resources and education. Interprets and communicates complex patient/family needs and role models caring practices to other caregivers.

Assess patients' and families' psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness, and ability to cope. Counsels patients and families regarding emotional, social, and financial consequences of illness and/or disability; accesses and mobilizes family/community resources to meet identified needs.

Social workers provide brief crisis counseling and therapeutic intervention with particular focus on frequent utilizers of the healthcare system. Post-discharge follows up phone calls are placed to high-needs utilizers of the ED in an effort to prevent readmission.

Social workers see all patients for whom their team is consulted and round daily with the multidisciplinary team. Generally, social work will see a patient for whom he or she has been consulted in any subsequent admissions as well.

• Provides therapeutic intervention to facilitate complex discharge planning by completing psychosocial assessments and high-risk screens after independent case-finding or receiving referrals. Based on the assessment, develops and documents a short-term treatment plan.

• Identifies the need for and conducts family meetings that result in comfort, decisions, and other important outcomes.

• Serves as the lead in obtaining charity and financial resources, legal guardianship, adoptions, psychiatric referrals, and competency determinations. Utilizes effective principles of interviewing alleged victims, perpetrators, family members, and significant others.
  
  Provides intervention for end-of-life, guardianship (temporary/permanent), foster care, adoption, etc. Serves as the point person in child abuse/neglect, adult/elderly abuse/neglect, institutional abuse, and domestic violence. Serves as liaison between Tampa General and state and county child and adult protective teams. Provides intervention in guardianship (temporary/permanent), foster care, adoption, and mental health level II placements.

• Participates in Care Coordination Rounds

• Helps create function and productivity on the many teams to which the SW belongs, facilitating the resolution of conflict in order to present a united message to patients and families.

• Leads or co-leads a standing support/education group for an at-risk population.

• Works with people and agencies in the community to improve responsiveness, capabilities, alignment, and evaluation of services to patients and families.

• Actively participates in clinical performance improvement activities.

• Completes all processes required to facilitate patients' movement through levels of care.

• Provides specialized mental health services including, but not limited to, Crisis Intervention and Addiction Assessments and recommendations for psychiatric referral or community resources. Supports those undergoing acute crisis which often results in the use of de-escalation techniques necessary to avoid episodes of physical violence.

MSW degree from a C.S.W.E.-accredited college or university Social Work program. At least 2 years' experience in a health care facility or program. Registered Clinical Social Worker Intern (RCSWI) required within 6 months of employment, Licensed Clinical Social Worker (LCSW) preferred.