The Social Worker carries an independent case load and is responsible for discharge planning and contributing to the patient’s treatment plan through an understanding of the patient’s social, psychological and/or environmental needs. Provides psychosocial assessment, counseling, crisis intervention and information or referral services to patients and families. This position is expected to work closely with the Case Manager on their assigned unit as a team to provide effective and seamless overall care management to all customers.
Provides patient care, treatment, and services within the scope of their license, certification, registration, and/or assessed competencies. Practice will be in accordance with laws and regulations and will adhere to established policies, procedures and practice guidelines.
- Assesses social, emotional and economic stresses of patients and families.
- Formulates a specific plan of intervention. All plans are developed in consultation with patient, family, case management team, and other members of the health care team. Proactively facilitates adjustment in the care plan or services when necessary to promote enhanced outcomes.
- Provides advocacy, assistance, support, counseling and crisis intervention to patients and families. In the case of suspected abuse/neglect/exploitation, the Social Worker documents and reports where required.
- Assists with identification of appropriate resources and functions in a liaison role between the hospital and community in making community resources available to the patient and family.
- Coordinates post-discharge needs and links patients/families to entitlements, community resources and other outpatient services. Facilitates patient placement for patients transitioning to non-acute care settings; i.e., skilled nursing facility, hospice, or personal care home. Ensures timely discharge planning and throughput initiatives.
- Provides education to patient/family in regard to effective use of community resources.
- Works closely with Financial Counseling regarding patient’s financial situation.
- Maintains current knowledge and researches availability of resources for social, emotional and financial assistance.
- Maintains timely and accurate documentation in the patient medical record including all elements of the discharge plan.
- Acts as facilitator and coordinator to the healthcare team with patients and families.
- Works with Case Manager to provide seamless overall case management services to customers including patients, families, physicians, nursing and quality improvement team, etc.
- Participates in continuous quality improvement teams and activities.
- Participates in supporting the organization’s vision, mission and values and adheres to DeKalb Medical Standards of Behavior.
- Performs other duties as assigned to meet the goals and objectives of DeKalb Medical.
Minimum Education, Experience and Licensure Required:
- Master’s degree in Social work required
- Three (3) or more years job related experience required
- Previous social work, discharge planning or equivalent experience in a hospital setting preferred
- Professional licensure preferred: LCSW or LMSW
Skills, Knowledge and Abilities:
- Strong interpersonal and communication skills necessary to obtain information from patients, provide counseling to patients/families, and interact effectively with patients, families and healthcare staff.
- Analytical skills necessary to assess patient’s needs, develop associated discharge planning and develop solutions to problems concerning patient’s mental and physical well being.
- Knowledge of and adherence to National Association of Social Worker's Code of Ethics.
- Performs skills and competencies as defined in orientation checklist and annual departmental competency checklist if applicable.
- Demonstrates and maintains competencies specific to patient population served.
Reports to: Manager, Case Management; daily oversight and guidance from Lead Case Manager
Positions Supervised: MSW Social Worker supervises BSW Social Worker