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Social Work Specialist

4 months ago

Tavares, Florida, United States AdventHealth Full time

All the benefits and perks you need for you and your family:

Benefits from Day One

Paid Days Off from Day One

Nursing Clinical Ladder Program*

Our promise to you:

Joining AdventHealth is about being part of something bigger. It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule: Full Time

Shift : Day Shift

The community you'll be caring for:

AdventHealth Waterman

1000 WATERMAN WAY, Tavares, 32778

The role you'll contribute:

The Social Work Specialist intervenes with patients who have complex psychosocial needs, require assistance with eligibility determination for social programs and funding sources and qualify for community assistance from a variety of special funds and agencies, and/or require assistance with transitions of care or discharge planning. In addition, offer crisis intervention to patients and families with psychosocial needs and coordinates and facilitates the development of a discharge plan of care for high-risk patient populations. This role will receive referrals for individuals from at-risk populations from interdisciplinary team members (including physicians, RN Care Managers, staff nurses, and other members of the care team).

The Social Work Specialist, in collaboration with the patient/family, care manager nurses, nurses, physicians and the interdisciplinary team, ensures patient-centered care coordination through the continuum of care. The Social Work Specialist ensures efficient and cost-effective care through appropriate resources monitoring, and clinical care escalations. The Social Work Specialist is under the general supervision of the Care Management Supervisor or Manager and is responsible for patient evaluations of post-hospital needs; development of a transition of care plans and initiation of the implementation of the transitions of care plans prior to the discharge of the patient. The Social Work Specialist is responsible for optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, readmission prevention and length of stay management. The Social Worker communicates daily with the interdisciplinary team during daily multidisciplinary rounds. Care coordination, discharge planning, transitions of care planning and are core competencies of this role. The Social Work Specialist facilitates the collaborative management of patient care across the continuum, intervening to remove barriers to timely and efficient care delivery and reimbursement. The Social Work Specialist provides education to nurses, physicians and the interdisciplinary team on issues related to utilization of resources, medical necessity, CMS CoP for Discharge Planning and care coordination. The Social Work Specialist is knowledgeable of post-hospital care and services available to the patient including, but not limited to the following: Home Health, Infusion Services, Durable Medical Equipment, Palliative Care, Hospice, Outpatient Services, Transitions of Care Clinics, Transitional Care supportive programs and clinics, follow up appointments, Skilled Nursing Facilities, Rehabilitation Services and Facilities and Community-based Organizations. The Social Work Specialist adheres to departmental and system goals, objectives, policies and procedures and ensures quality patient care and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

The value you'll bring to the team:

PRINCIPAL DUTIES AND JOB RESPONSIBILITIES :

· Psychosocial Assessment and Interventions

o Assesses patient's and family's psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope

o Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability; accesses and mobilizes family/community resources to meet identified needs

o Serves as a resource to provide information and intervention related to treatment decisions and end-of-life issues

o Provides grief counseling and crisis intervention skills

o Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the healthcare system

o Provides de-escalation services for patients as appropriate

o Provide Motivational Interview techniques for patients with substance use and addictive disorders.

o Provides patient/family education, adjustment-to-illness counseling, grief counseling and crisis intervention. Provides education to patients/families/caregivers regarding resource options and coping with diagnosis, treatment and prognosis.

o Works in collaboration with hospital and community agencies to obtain needed services and resources for patients/families/caregivers.

· Receives referrals for psychosocial complex problems from the health care team.

· Provides assessment and reporting interventions in child abuse/neglect, domestic violence, adult/elderly abuse, child protection and sexual assault, as appropriate

· Provides consult services for patients who may possibly lack decision making capacity. Follows the guardianship (temporary/ permanent) policies sand procedures and coordinates with Care Management leadership throughout the process

· Provides consult services for foster care and adoptions.

· Assists the health care team in the patient assessments and placements for mental health services.

· Facilitates full team discussion including patient and family when ethical dilemmas arise

· Completes Initial Evaluation for transition of care needs on all identified patients within one calendar day of admission and documents according to policies and procedures. Interviews patient and involved care givers (as permitted by the patient) as well as a review of the current and past inpatient and outpatient medical record in the Initial Evaluation.

· Reviews necessary patient information including labs, medications (Pre and post hospital), History and Physical, Therapy notes, ED notes, test results and progress notes.

· Incorporates the patient/family care goals and preferences as much as possible into the transition of care planning and communicates these goals and preferences to the multidisciplinary team.

· Incorporate clinical, social and financial factors into the transition of care plan.

· Meets with patient/families to discuss realistic and appropriate discharge options and providers of post-hospital care.

· Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to meet the individual needs of each patient

· Identifies and collaborates with the interdisciplinary team and hospital operations to resolve potential barriers to transition of care plan achievement.

· Collaborates with the multidisciplinary healthcare team daily in multidisciplinary rounds to efficiently communicate and facilitate high quality patient progression of care and transitions plans.

· Evaluates the potential for readmissions throughout the patient stay through the monitoring of each patient's readmission risk scores and coordinating readmission mitigation interventions.

· Assures Social Work consults are completed for specialty services related to psychosocial needs, decision making needs for patients who lack capacity, patient/family adjustment needs and psychosocially complex cases.

· Develops discharge plan with appropriate contingency plans throughout the hospital stay to enable adaptation to evolving patient care needs and ensure timely care coordination.

· Escalates issues barriers to appropriate level of Care Management leadership

· Assists with End of Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR.

· Facilitates patient care conferences with multidisciplinary team as needed.

· Establishes and documents, based on the predicted DRG and multidisciplinary team member's input, Anticipated Date of Transition (ADOT) and destination and updates, as needed.

· Actively participates in daily Multidisciplinary Rounds to review progression of care and discharge plan for all assigned patients

· Proactively identifies patients who no longer meet medical necessity and escalates potential denials, documents avoidable days, and facilitates progression of care.

· Collaborates with Utilization Management staff for collaboration on patient status changes and medical necessity discussions.

· Ensures all patients on assigned unit(s) are moved timely and effectively to appropriate levels of care

· Ensures reassessment of discharge needs provided anytime a patient's condition changes and/or the circumstances impacting the provision of post-hospital care changes.

· Ensures patient notifications are provided and documented in a timely manner for compliance: Important Medicare Letters (IML), Medicare Outpatient Observation Notice (MOON), Patient Choice, and Beneficiary Notice Letter (BNL).

· Communicate with patient/family the possible need to pay for services out of pocket.

· Ensures primary care physician identification and scheduling of follow-up PCP and specialist appointments for post-hospital follow up care.

· Ensures discharge disposition accuracy and consistency in the EMR on all discharge patients.

· Serves as a content expert regarding payor information and educates interdisciplinary team and patients/caregivers regarding payor requirements/barriers.

· Maintains clinical competency and current knowledge of community resources, post-acute care providers and payor requirements to perform job responsibilities.

· Participates in department and hospital Performance Improvement activities.

· Provides necessary patient care coverage and assistance with other duties as assigned when needed.

· Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization.

· Participates in facility and department regulatory and certification preparations. Qualifications

EDUCATION AND EXPERIENCE REQUIRED:

· Bachelor's in Social Work

· Minimum three (2) years experience in hospital/medical social work

EDUCATION AND EXPERIENCE PREFERRED:

· Masters in Social Work

· Care Management discharge planning experience

· Knowledge of state and federal guidelines pertinent to care management

LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:

LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:

· Licensed Clinical Social Worker (LCSW)

· ACM/CCM certification

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.