Under general supervision, coordinates and procures individualized plans and services to meet the psychosocial and discharge needs of neonatal through geriatric patients and their families, enabling patients to properly utilize medical care and health care resources in achieving their optimal level of physical and emotional health. Works collaboratively with interdisciplinary staff, internal and external to the organization, in managing the patients care across the continuum.
Unit Specific Position Responsibilities
Assesses and identifies current, potential, and ongoing psychosocial and discharge needs of patients and families, implements, evaluates and revises the plan of care as needed with the assistance of the interdisciplinary health care team.
Evaluates patients eligibility for home care nursing services, Hospice services, nursing home services, assisted living services, home medical equipment, and financial assistance.
Coordinates nursing home placements, assisted living placements, skilled care services, skilled care referrals, home care referrals, Hospice referrals, obtaining home medical equipment, and financial counseling.
Coordinates transportation services as needed.
Provides options, services' rates and other pertinent information related to the various health care/community resources available.
Provides emotional counseling to patients and families on various subjects related to patients illness/condition, hospitalization, and treatment.
Provides crisis intervention services for patients and their families as needed.
Collaborates with various health care members, internal and external to the organization, with regard to discharge plans and concerns.
Attends and participates in the interdisciplinary discharge planning meetings or patient care conferences.
Obtains appropriate orders for appropriate discharge disposition, discharge service, equipment, etc. as needed.
Maintains appropriate documentation of assessment, discharge plan, coordination activities, and progress within the plan.
Accepts and processes referrals related to adoption services.
Qualifications, Knowledge & Experience
Required Qualifications (Including any licensure, certification, education):
Graduation from college with a bachelors degree in social work (BSW) or related field. Two years of social work experience in a health care setting preferred.
Knowledge of the theories, principles, and techniques of social work treatment and assessment; knowledge of the psychosocial aspects of health care; knowledge of public and private welfare and health agencies available to serve the community; knowledge of current laws, rules, regulations and guidelines affecting Social Services activities and services and its clientele; knowledge of current laws, rules, regulations, guidelines and professional codes of ethics as they apply to confidentiality of patient/client and organizational records and information.
Ability to read, write, speak and understand the English language; to demonstrate basic computer skills; to evaluate the appropriateness of diagnoses and procedures; to read and understand chart documentation; to keep current with changes in the medical field; to demonstrate skills and current knowledge in patient assessment.
Must be able to effectively communicate in a professional and tactful manner with physicians, staff, patients and/or their representatives. Must be able to publicly present information to physicians, members of the care team, and others as appropriate. Must be self-directed, flexible, and able to adapt to change. Must maintain confidentiality.
Ability to demonstrate clinical competence and maintain current knowledge in caring for neonatal through geriatric patients.
Required Knowledge, Skills & Experience:
Preferred Knowledge, Skills & Experience: