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Social Worker MSW
4 weeks ago
Key Responsibilities:
- Complete thorough chart reviews upon referral and throughout patient stays.
- Attend Bed Huddles and Care Conferences daily to promote throughput activities.
- Provide information to Care Coordinators and Charge Nurses related to pending and confirmed discharges.
- Participate in ongoing communication with physicians and the interdisciplinary team to develop a collaborative relationship aimed at improving clinical treatment goals and timely discharge.
- Proactively educate patients about advance directives, post-acute services, and community resources available at discharge.
- Complete proactive initial and ongoing psychosocial assessments to identify complex post-acute needs.
- Provide support to patients with issues related to adjustment to illness and assist in securing support post-hospitalization.
- Identify hospital and community-based resources to meet patient/family needs and provide referrals and advocacy.
- Maintain active interaction with patients/families throughout the treatment/discharge planning process.
- Make appropriate referrals to internal and post-acute service providers to ensure continuity of care.
- Provide expertise to the team in developing treatment and discharge planning strategies for frequently admitted patients.
- Assist in the procurement of services and serve as an advocate on behalf of patients/families for scarce resources.
- Maintain high team standards by addressing coordination problems within the functioning of the healthcare team.
- Identify and escalate issues related to LOS/Throughput/Readmission management.
- Provide education to patients, families, and hospital staff regarding post-acute services.
- Graduate of an accredited master's school of social work.
- Licensed as an SW to practice social work in the state where work is being performed.
- Meets contact hour requirements for licensure, including all state required courses.
- Knowledge of psychosocial issues related to health-related problems and post-acute care needs.
- Excellent communication skills and ability to coordinate care well with an interdisciplinary team.
