Social Worker-Acute Care Transition Team

White Plains Hospital Center White Plains , NY 10601

Posted 1 month ago

Position Summary #As a key member of the Acute Care Transition Team (ACTT # #WPH Cares#), the WPHC Care Manager will play an important role to help with process improvement in patient outreach and coordination of care for WPH discharged patients.# WPHC Care Manager is a creative problem solver who will be responsible for solving the needs of complex patients; acute care high utilizers and in many cases, high utilizers whose social determinants of health impede the path to recovery.# As a member of WPH Cares, the WPHC Care Manager will serve two main functions: WPH Cares # connecting with patients within 48 hours of discharge from WPH with the goal of a 100% contact rate. They will work to answer general and specific questions in regards to the patient#s recent medical encounters and history, plan of care, potential clinical complications and discharge instructions.# They will work with other WPHC and Care Management team members to bridge the divide from the hospital setting to home.# The WPHC Care Manager will support the acute care staff that has recently rendered care, our patients, and their family members as they navigate the healthcare system at White Plains Hospital (WPH) and our affiliates. WPHC Care Manager will help to facilitate two-way communication between the acute clinical setting and the home environment and includes encounters from the emergency department, inpatient setting, observation, labor # delivery, and/or ambulatory surgery. Some examples of the team#s responsibilities will include but not be limited to: Medication management Access to care, care linkages and community resources Outpatient follow-up coordination both within WPH as well as our affiliates# Post-acute care phone calls to assess needs, overall satisfaction, and missed opportunities Assessment of social determinants of health that may be inhibiting the journey back to health High risk clinical follow-up Expedited outpatient testing Incoming transfers Care Management # (leverages and manages the) comprehensive assessment on admission in accordance with the Care Management Department policy,# to ensure high- and low- risk patient populations receive the appropriate supportive services for discharge to prevent readmission and assess all populations for potential discharge planning needs. Provides ongoing reassessment of needs throughout the hospital stay.


Troubleshoot the following:


Patient/Caregiver education Arrangement of aftercare Commercial payer involvement (who is supposed to do auths for drugs?) Community resources The WPHC Care Manager will serve as a representative and voice for WPH Cares in a variety of hospital committees and teams, for example: Readmission Task Force, Weekly Readmissions, Care Management (monthly meetings), ad hoc #in service# meetings and other cyclical huddles that impact coordination of care. #Education # Experience Requirements ' Master of Social Work Degree from a School of Social Work accredited by the Council of Social work education. ' Certified Social Worker approved by the State Education Department of the University of the State of New York. ' Two years of experience in an acute care hospital setting or related setting. #

Position Summary

As a key member of the Acute Care Transition Team (ACTT - "WPH Cares"), the WPHC Care Manager will play an important role to help with process improvement in patient outreach and coordination of care for WPH discharged patients. WPHC Care Manager is a creative problem solver who will be responsible for solving the needs of complex patients; acute care high utilizers and in many cases, high utilizers whose social determinants of health impede the path to recovery. As a member of WPH Cares, the WPHC Care Manager will serve two main functions:

  • WPH Cares - connecting with patients within 48 hours of discharge from WPH with the goal of a 100% contact rate. They will work to answer general and specific questions in regards to the patient's recent medical encounters and history, plan of care, potential clinical complications and discharge instructions. They will work with other WPHC and Care Management team members to bridge the divide from the hospital setting to home. The WPHC Care Manager will support the acute care staff that has recently rendered care, our patients, and their family members as they navigate the healthcare system at White Plains Hospital (WPH) and our affiliates. WPHC Care Manager will help to facilitate two-way communication between the acute clinical setting and the home environment and includes encounters from the emergency department, inpatient setting, observation, labor & delivery, and/or ambulatory surgery. Some examples of the team's responsibilities will include but not be limited to:

  • Medication management

  • Access to care, care linkages and community resources

  • Outpatient follow-up coordination both within WPH as well as our affiliates

  • Post-acute care phone calls to assess needs, overall satisfaction, and missed opportunities

  • Assessment of social determinants of health that may be inhibiting the journey back to health

  • High risk clinical follow-up

  • Expedited outpatient testing

  • Incoming transfers

  • Care Management - (leverages and manages the) comprehensive assessment on admission in accordance with the Care Management Department policy, to ensure high- and low- risk patient populations receive the appropriate supportive services for discharge to prevent readmission and assess all populations for potential discharge planning needs. Provides ongoing reassessment of needs throughout the hospital stay. Troubleshoot the following:

  • Patient/Caregiver education

  • Arrangement of aftercare

  • Commercial payer involvement (who is supposed to do auths for drugs?)

  • Community resources

The WPHC Care Manager will serve as a representative and voice for WPH Cares in a variety of hospital committees and teams, for example: Readmission Task Force, Weekly Readmissions, Care Management (monthly meetings), ad hoc "in service" meetings and other cyclical huddles that impact coordination of care.

Education & Experience Requirements

  • ' Master of Social Work Degree from a School of Social Work accredited by the Council of Social work education.
  • ' Certified Social Worker approved by the State Education Department of the University of the State of New York.
  • ' Two years of experience in an acute care hospital setting or related setting.
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Participates in the department#s cross-training program. 20. Responds and participates in external and internal disasters when indicated/assigned by supervisor. 21. Performs other duties assigned as needed Education # Experience Requirements ? Master of Social Work Degree from a School of Social Work accredited by the Council of Social work Education. ? Licensed Social Worker (LMSW/LCSW) approved by the State Education Department of the University of the State of New York. ? Two years experience in an acute care hospital setting or related setting. ? NYS SCREEN Certification Core Competencies Ability to relate cooperatively and constructively with patients, families, significant others, co-workers, physicians and other staff members Physical/Mental Demands/Requirements # Work Environment ? May be exposed to chemicals necessary to perform required tasks. 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Completes Social Work Comprehensive Assessment for all patients referred or in need of social services in accordance with departmental high risk criteria policy. 3. Complies with social work documentation and its requirements. 4. Provides psychosocial information for patients transferring to other units to ensure continuity of care. 5. Provides supportive counseling, crisis intervention, and grief counseling to patients and their families/ significant others as appropriate. 6. Assists patients with adjustment to treatment, including problems of depression, anxiety, denial and/ or anger; noncompliance with medical regimen. 7. Devises/implements a social work treatment/continuing care plan involving the patient, family/significant other and the interdisciplinary team and documents on the patient's medical record in accordance to the departmental policy. 8. Provides information, referral and advocacy to community agencies. 9. Advocates and serves as a liaison for patients with community agencies. 10. Coordinates individual interdisciplinary case conference as needed. 11. Provides task supervision to caseworkers when designated. 12. Provides direct/task supervision to social work assistants and/or social work students when designated. 13. Leads education and support groups for patients and/or families/significant others as appropriate. 14. Identifies, evaluates and designs proper safety plans for victims of crimes/abuse, i.e.: child abuse, elder abuse, domestic violence, rape and sexual assault. 15. Maintains and completes statistics of case activities as outlined in the departmental policy. 16. Monitors his/her performance by reviewing medical records for appropriate documentation. 17. Attends individual, unit, departmental and intra/inter hospital meeting as mandated by the supervisor and/or department director. 18. Assists /Participates in presentations, training and in-services as required. 19. Participates in the department's cross-training program. 20. Responds and participates in external and internal disasters when indicated/assigned by supervisor. 21. Performs other duties assigned as needed Education & Experience Requirements ? Master of Social Work Degree from a School of Social Work accredited by the Council of Social work Education. ? Licensed Social Worker (LMSW/LCSW) approved by the State Education Department of the University of the State of New York. ? Two years experience in an acute care hospital setting or related setting. ? NYS SCREEN Certification Core Competencies Ability to relate cooperatively and constructively with patients, families, significant others, co-workers, physicians and other staff members Physical/Mental Demands/Requirements & Work Environment ? May be exposed to chemicals necessary to perform required tasks. Any hazardous chemicals the employee may be exposed to are listed in the hospital's SDS (Safety Data Sheet) data base and may be accessed through the hospital's Intranet site (Employee Tools/SDS Access). A copy of the SDS data base can also be found at the hospital switchboard, saved on a disc. ? Must be physically able to write, read, and move quickly throughout the work environment and hospital. Must also have the dexterity to operate computers and other office equipment. ? Must have the ability to assess a patient's situation, formulate a plan according to need and follow through to resolution. ? Must be able to communicate with patients and others in a sensitive and caring manner and to visually assess a patient's affect and body language. White Plains Hospital Center White Plains NY

Social Worker-Acute Care Transition Team

White Plains Hospital Center