The Social Worker is responsible to identify and create action plans to meet the social, psychosocial, environmental and/or discharge planning needs of patients and families. The social worker a ssists patients and families in maximizing the utilization of health care and community resources in order to achieve their optimal level of wellness.

Assesses patient situation and identifies patient care and discharge needs:

• Performs psychosocial assessment on high risk and referred patients to determine psychosocial and discharge planning needs
• Assesses family/social support
• Works with other interdisciplinary team members to assess patient's functional capacity, need for community services or placement to meet identified care needs
• Assesses cognitive and coping abilities of patient/caregivers and ability to carry out plan
• Analyzes assessment and medical data to prioritize needs and determine priority problem(s)
• Documents assessments and interventions on interdisciplinary care plan and medical record
• Obtains input from patient and family caregivers regarding their needs and desires
• Assures that assessments, interventions and teaching plans reflect the developmental level needs of patient/family

Develops and facilitates timely individualized patient care and discharge plans:

• Attends interdisciplinary team meetings and collaborates regularly with team
• Arranges and mobilizes a range of community resources to meet identified patient/family needs
• Formulates plan, communicates and educates patient/caregivers and referral sources about plan details to assure common understanding and agreement with plan; evaluates effectiveness of learning
• Modifies plan based on patient's evolving needs and wishes
• Collaborates with agencies and case managers already involved in patient's care
• Documents evolving assessments and plans

Provides a range of generalist social work interventions to assist patients and families reach their goals:

• Facilitates case management, crisis intervention, problem solving, supportive counseling, group work, psychoeducation, information and referral services, and abuse reporting as appropriate
• Identifies rapidly changing situations and intervenes to prevent or resolve a crisis, increased length of hospital stay or unnecessary hospital admission
• Identifies mental health issues and refers to appropriate provider for intervention and follow-up
• Provides information and referral to community members and ambulatory care settings and maintains community resource file

Advocates for individual patients, families and patient groups from social work theory and practice perspectives:

• Educates health care team members regarding social work role
• Educates health care team members and community on pertinent patient care issues, community resources, financial impact issues, patient rights and population specific information
• Serves as patient advocate and liaison with physician, interdisciplinary team and community services/agencies to ensure continuity of care and to meet patient needs
• Provides macro social work intervention to health care system by identifying barriers/issues related to providing patient care.
• Participates in quality improvement processes to improve services to patients/families

Seeks to advance the field of social work:

• Promotes ethical social work practice as defined by the licensing and professional organizations that regulate the profession
• Serves as preceptor or field instructor for social work undergraduates and new employees. (not applicable to home care)
• Serves entity committees as appropriate
• Engages in clinical supervision as defined by the entity

Minimum qualifications of a BSW would prefer a LICSW

Experience in Case Management with inpatient patients is desired.

Canidate must commit to working 1 week for the first week of orientation