JOB DESCRIPTION: Independently assesses, coordinates, and implements a timely, safe patient discharge plan to the appropriate level of care. Participates in interdisciplinary approach to patient care management. Provides emotional support and psychosocial counseling to patients. Acknowledges and appropriately prioritizes referrals from interdisciplinary team members, patients, and families, with initial chart documentation entered within eight business hours of receipt of consult. Attends and actively participates in Triads and interdisciplinary team meetings in order to screen for high risk patients, obtain and share information, identify appropriate length of stay per DRG, advance the patient's plan of care, identify and take action to resolve barriers and to coordinate safe and appropriate discharge to the proper level of care within the appropriate time frame. Maintains focus on the provision of quality service in a rapid and efficient manner in order to transition patients to the appropriate level of care within the time frame of the target length of stay. Updates the clinical team regarding discharge destination, and date and time of anticipated discharge. Attends and actively participates in Traid Data Meetings and Team Meetings in order to identify and address system trends and barriers to the delivery of efficient patient care. Collaborates with insurance case managers and community care providers, and initiates referrals to appropriate community resources. Maintains a thorough working knowledge of Medicare, Medicaid and private payer regulations and processes. Maintains broad knowledge of resources and options for patients available within all levels of care: facilitates efficient access and movement of patient across levels of care, and coordinates inter-facility transfer of patients to appropriate level of care. Ensures that a safe and timely discharge is attained, with proper documentation and verbal reports shared with receiving facilities or agencies. Respects the confidentiality of all patient information and conforms to hospital/departmental policies on the handling and disclosure of patient information. Acts as a responsible steward of department's patient care funds, exploring all viable options prior to requesting use of funds. Assesses patients and members of their support system in order to identify potential needs, to determine appropriate level of care for discharge planning purposes and to identify necessary interventions. Evaluates family, home environment and financial situation in order to develop safe and viable plan of care. Provides patient and family counseling and education regarding discharge planning, and community resources. Provides supportive counseling for patients, families and significant others who are experiencing anxiety or stress due to illness, injury or physical limitations. Takes an active role in the coordination and facilitation of goal-oriented family meetings. Evaluates, coordinates and acts in accordance with current laws and hospital policies in reporting targeted populations (suspected child/disabled adult/elder abuse or neglect). Demonstrates a high level of initiative and performs as a self-starter in daily activities. Efficiently covers for colleagues as requested, and thoroughly conveys patient care status and plan of care in order to assure continuity and uninterrupted service upon colleagues' return. Thoroughly prepares covering colleagues in advance of planned absences. Demonstrates the skills necessary to nurture teambuilding and growth in establishing and maintaining a cooperative relationship with professionals, physicians, patients, family members and community agency representatives. Assumes responsibility for seeking guidance in areas of question by consulting supervisor and colleagues as necessary. Appropriately escalates cases. Acts in a professional, caring, customer service focused manner in all interactions with patients, families, peers, medical team members and community agency representatives. Supports and participates in multidisciplinary patient/family education and care planning with the entire healthcare team. Develops educational materials and programs to meet the needs of assigned patient population, and to meet the education needs of the medical team and social work peers. In collaboration with supervisor, pursues professional development opportunities through local, regional and national forums. Participates as a member of professional organizations in order to establish resource network, and to maintain knowledge of current practices, trends and developments. Acts as a professional resource for colleagues within and outside the organization. Provides education to the community as needed. Documents in an accurate, timely and thorough manner in accordance with departmental policy. Records assessment, ongoing contacts, and final discharge plan including level of care to which patient is being transferred. Completes all necessary paperwork and computer documentation in order to Assures continuity of care, accurate reimbursement to the organization, and compliance with regulatory requirements. Obtains and communicates information through timely and efficient use of available computer applications (Healthquest, EeMR, Groupwise, Social Services Lotus Notes Database and the internet). Reviews and interprets Length of Stay Data Reports and Patient Satisfaction Survey Reports with intent of improving service delivery and meeting organization goals. Completes additional assignments/projects as directed by the department leaders.
MINIMUM QUALIFICATIONS: Master's of Social Work degree from an accredited school of social work. One year of medical social work experience in an acute care setting. Positions in this classification require license or license eligibility. Knowledge of computer software applications.
PHYSICAL REQUIREMENTS (Medium): 20-50 lbs; 0-33% of the work day (occasionally); 11-25 lbs, 34-66% of the workday (frequently); 01-10 lbs, 67-100% of the workday (constantly); Lifting 50 lbs max; Carrying of objects up to 25 lbs; Occasional to frequent standing & walking, Occasional sitting, Close eye work (computers, typing, reading, writing), Physical demands may vary depending on assigned work area and work tasks.
ENVIRONMENTAL FACTORS: Factors affecting environment conditions may vary depending on the assigned work area and tasks. Environmental exposures include, but are not limited to: Blood-borne pathogen exposure Bio-hazardous waste Chemicals/gases/fumes/vapors Communicable diseases Electrical shock, Floor Surfaces, Hot/Cold Temperatures, Indoor/Outdoor conditions, Latex, Lighting, Patient care/handling injuries, Radiation, Shift work, Travel may be required. Use of personal protective equipment, including respirators, environmental conditions may vary depending on assigned work area and work tasks.