Performs psychosocial screenings and/or assessments to ensure that patient needs are properly identified and appropriate interventions are integrated into the plan of care. 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, understanding of present circumstances and patient/family priorities/needs. Collaborates with the patient, family and multidisciplinary team to assure psychosocial needs are addressed. Utilizes review of medical record, interview of patient/family and consultation with the interdisciplinary health care team to complete screenings/assessments/plan of care.
Counsels patients and families regarding emotional, social, and financial consequences of illness and/or disability and other psychosocial issues identified. Provides crisis intervention and counseling for patients and families. Promotes patient and family empowerment and independence by connecting patient needs to services provided at the local, state and federal level.
Monitors the patient’s progress, intervening as necessary and appropriate to ensure the Social Work plan of care and services provided are patient focused, high quality, efficient, and cost effective. Coordinates referrals for financial counseling as appropriate. Addresses and resolves system barriers and provides follow-up as needed.
Promotes optimal utilization of patient and community resources. Provides planning for placements including Home, Nursing Home, Rehabilitation, Shelters, Home Care and HOSPICE. Accesses and mobilizes family/community resources to meet identified needs. Intervenes with families with complex psychosocial needs and family dynamics. Educates patient/family about options and addresses issues of choice.
Transitions patients through the healthcare system based upon individual and patient population needs. Directs liaison activities to appropriately integrate the patient into the healthcare continuum including procuring of services, health promotion and counseling, disease prevention, health education and screening, and community resource linkage.
Serves as an advocate for the patient and family throughout the entire episode of care. Maintains availability to the patient/family as a resource to facilitate communication among providers and to monitor services rendered. Remains involved until the planned level of functional health is achieved by the patient.
Communicates newly identified resources or changes in previously identified plans/resources.
Provides intervention in cases involving child or adult abuse/neglect (serves as liaison between Parkland and CPS/APS), domestic violence, guardianship (temporary/ permanent), foster care, adoption, mental health level II placement, and sexual assault.
Documents screening, assessment, interventions and outcomes to ensue effective communication per established documentation procedures.
Manages referrals and communications from a variety of sources such as fax referrals, calls, physicians, COPC Social Workers, Care Management Team, the health dept team, community agencies, patients, families, etc. to ensure optimal customer service.
Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the Social Work field. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal/state/private health plans. Seeks advice and guidance as needed to ensure proper understanding.
Maintains positive working relationship with management, vendors, other hospitals, employees, and community agencies to ensure effective communication among all patient contacts. Keeps staff informed, makes reports, rounds and frequent agency contacts to ensure appropriate support.
Reports assigned data (i.e. services provided, Medicare stats, alcohol and drug numbers, adoption numbers, CPS/APS cases) as needed, ensuring timeliness and accuracy.
Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements and monitors results as appropriate in support of the overall goals of the department and Parkland.
Stays abreast of the latest developments, advancements and trends in the field of Social Work by attending seminars or workshops, reading professional journals, actively participating in professional organizations and maintaining licensure in Social Work. Integrates this acquired knowledge into daily performance.
Serves on committees as selected and assigned. Participates in social work peer review, social work meetings and other efforts that promote quality and patient satisfaction.