Social Worker - Inpatient

POSITION PURPOSE Assists patients and families in coping with problems associated with severe and long‑term illnesses. Conducts patient and family interviews, prepares psychosocial assessments, develops treatment plans, provides counseling and crisis intervention, and directs patients to designated community agencies and resources. Responsible for coordinating the health care plan – including discharge plans from the acute setting and transitions of care to the post‑acute care network – for assigned patient populations through the use of care plans, critical pathways, managed care and collaboration with all members of the health care team. Evaluates care based upon quality, access, and cost‑effectiveness. Maintains the continuum of care through the coordination and integration of all phases of patient care. Provides consultation to patient treatment team members and participates in developing new patient care programs. In various SJMH settings, may provide individual, family, and/or group treatment as part of interdisciplinary treatment plan. Provides quality patient care considering age‑specific, developmental, cultural, spiritual, diversity, and/or other special needs or circumstances through competent clinical practices. ESSENTIAL FUNCTIONS AND RESPONSIBILITIES Functions as a member of the interdisciplinary care management team. Interviews patients and families to obtain psychosocial data. Evaluates and gathers data from patients, families, outpatient supports, and other collateral sources regarding plan of treatment and available resources, and develops an appropriate intervention plan. Provides a variety of direct services and clinical interventions to maintain continuity of care and help patients and families resolve socio‑emotional problems associated with adjustment to illness, resource needs, mental health problems and life events and transitions. Coordinates care of identified high‑risk patient populations across the continuum, addressing psychosocial issues. Collaborates with patients, families and primary care providers to develop plans that influence health care utilization, including services for home and facilitating hospital‑to‑hospital transfers, hospice, extended care facility, acute rehabilitation and long‑term care facility placement. Refers patients to designated community agencies or resources for financial assistance, counseling, mental health and substance abuse follow‑up, and other support services. Conducts continuity of care planning, assessing needs and support services for home, and facilitates necessary transfers. Accounts for discharge planning and continuing care needs, including assessing, developing, and implementing continuing care plans based on patient self‑care, knowledge, and social support deficits. Conducts ongoing assessment and interdisciplinary collaboration regarding continuing care needs through the continuum. Initiates referrals to other providers and disciplines (e.g., Infectious Diseases, Risk Management) and to skilled home care, durable medical equipment vendors and other appropriate referral sources. Provides ongoing assessment of educational needs of patients/families, develops appropriate interventions and programs, and maintains relationships with community resources. Demonstrates ability to make appropriate and useful changes in the patient’s treatment plan when problems persist and recognizes when discharge or transfer of care is in the best interest of the patient. Advocates, educates, and facilitates resolution of patient rights, ethical and legal issues such as advance directives, end‑of‑life decisions, and guardianship. Systematically identifies and addresses barriers and fragmentation of care while proactively collaborating to find solutions. Documents social work assessment data and progress notes for each patient, including psycho‑social concerns, patient and family supports and needs, and intervention plan, in accordance with department documentation standards. Provides consultation to other patient treatment team members regarding socio‑emotional factors that affect patients and families. Communicates regularly with departmental and community agency personnel to coordinate services, exchange patient information, and ensure continuity of care. Utilizes population data to identify trends, potential intervention areas, and uses metrics to establish measurable goals and monitor outcomes. Uses professional expertise to advance policies and practices that improve access to care, ensure timely follow‑up, and support evidence‑based clinical management. Develops, implements and monitors clinical (and non‑clinical) quality improvement processes and regularly prepares and presents written reports tracking outcomes of interventions. Provides Social Worker leadership in related committees, task forces and work groups focused on improved health outcomes for the populations served. Serves as a change‑agent and resource to foster adoption of process, service and system improvement initiatives at various points of service. Advises on social policies in community development programs and understands legal issues that affect treatment, including child custody, divorce laws, abuse laws, duty to warn, recipient rights policies and procedures, alternative treatment orders and inpatient hospitalization commitments. Maintains knowledge of current trends and developments in the field. Assumes responsibility for performing job duties in the safest possible manner, ensuring personal safety, reporting preventable hazards and unsafe practices to management or via the anonymous reporting system. Attends and participates in departmental, health system, and community committees and meetings as necessary. REQUIRED EDUCATION, EXPERIENCE AND CERTIFICATION/LICENSURE Education: Master’s Degree in Social Work from an accredited graduate school. Experience: None (experience preferred). Certification/Licensure: Current State of Michigan Master’s Degree Social Work License (or Limited License MSW). LLMSWs are required to obtain an LMSW as prescribed by the state licensing board. REQUIRED SKILLS AND ABILITIES Interpersonal skills necessary to obtain information, provide counseling and interact effectively with patients, families and SJMHS colleagues. Analytic skills necessary to assess patients’ needs, develop discharge plans and provide sound advice and guidance. Ability to concentrate and pay close attention to detail for up to 90% of work. Must be mobile enough to move between nursing units and outpatient settings and in/out of patient rooms and offices. Demonstrates successful and progressive leadership and initiative. Demonstrates consistently high levels of clinical competence with demonstrated ability to provide clinical interventions at the individual, family, group, system and community level. Ability to function effectively within a multi‑disciplinary team. Demonstrated ability to provide quality patient care considering age‑specific, developmental and cultural needs. Equal Employment Opportunity Statement We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law. #J-18808-Ljbffr Trinity Health Mid-Atlantic