Discharge & Care Coordination Social Worker II

Job Description Primary Purpose: Provide comprehensive psychosocial services to patients and families at The Christ Hospital by assessing needs and developing individualized discharge plans to ensure continuity of care. This role includes delivering psychosocial interventions, advocating for patients, and connecting them with appropriate community resources.

ASSESSMENT/SCREENING

Assess patients' evolving medical situation from a psychosocial framework, including functional status, goals of care, and community support needs as it relates to discharge planning Assess family structure, dynamics, and decision-making preferences, including identification of a surrogate decision maker if needed Assess patient/family environmental risk factors, patient/family/community support systems, age-related/developmental issues, financial barriers, health literacy, chemical dependency/mental health, Social Determinants of Health needs, and any risk of abuse/neglect/financial exploitation/intimate partner violence Assess for risk of readmission, putting into place a coordinated plan for outpatient follow up Documentation: Documents in Discharge Planning progress notes a clear, concise, objective psychosocial assessment, treatment plan, and progress of social work intervention and outcomes in compliance with regulatory standards and department standards for timeliness. Documents appropriately in the Social Work module for data tracking purposes Responsibilities

DISCHARGE PLAN IMPLEMENTATION/CARE COORDINATION

Develop a plan of intervention, which is integrated with the interdisciplinary treatment team to establish continuum of care in congruence with ethical and legal considerations. Implements plan of care: Provide psychosocial counseling and other therapeutic interventions for patient/family Provide crisis management for patient/family Facilitate healthcare decision making and resolution of discharge planning issues Provide psychosocial intervention for: neglect/abuse/intimate partner violence/human trafficking; adjustment to illness; bereavement and mental health; substance abuse; non-compliance, and other psychosocial barriers to diagnosis and treatment Mandated reporting to local/state agencies as required by law - Adult Protective/Child Protective Services, law enforcement Maximize health status and minimize length of stay and appropriate utilization of hospital resources Provide referral and linkage to health care and community resources based upon Social Determinants of Health screening needs Facilitate extended care facility placement and hospital to hospital transfer Facilitate home care, hospice care, and durable medical equipment arrangements Advocate, mediate and negotiate a cohesive plan for maintaining or improving social supports and patient safety Coordinate patient's discharge plan with outpatient counterparts - TCHMA SW, insurance case managers, community mental health/substance abuse case managers - to aid in readmission prevention

CONSULTATION/EDUCATION/COLLABORATION

Attend unit specific Inter-Disciplinary Rounds daily Collaborate with interdisciplinary team to enhance quality of care and efficiency. Maintain a positive working relationship with healthcare team and community agencies and services. Provide extensive education to patient/family in areas of insurance benefits, and capacity of community resources to meet patient needs Participate in interdisciplinary patient care rounds, case conferences and family conferences for purpose of appropriate length of stay discharge planning. Assist interdisciplinary team in understanding significant social and emotional factors related to illness. Identify barriers in service delivery systems and advocate for change. Provide education to interdisciplinary team, residents, students, other disciplines and community agencies Evaluate patient outcomes and participate in process improvement.

CONTRIBUTIONS TO THE SOCIAL WORK DEPARTMENT

Provide leadership and perform delegated management responsibilities. Provide clinical supervision to peers, Bachelor degree staff, and students. Provide mandatory and/or voluntary cross coverage when needed. Participate in orientation of new staff. Generate and support ideas to improve Social Work Department service delivery systems. Identify complex clinical cases and seek supervision when appropriate Qualifications

KNOWLEDGE AND SKILLS:

Exceptional skill interviewing patients and families in crisis and individuals with a wide range of physical and emotional problems. Ability to prioritize many simultaneous demands. Medical and psychiatric competence including knowledge of health policy, regulations, and legislation and community resources. Self-awareness, professionalism, and good judgment in dealing with emotional and confidential issues. Excellent verbal and written communication. Skill in social work assessment and treatment modalities necessary to assess and treat individuals, families and groups. Ability to integrate social work philosophy and ethics into professional practice.

EDUCATION:

Master's degree in social work (MSW) required. LSW/LISW required. YEARS OF EXPERIENCE: 2 years clinical experience in hospital, long-term care or hospice setting preferred.

LICENSES & CERTIFICATIONS:

Assure ongoing licensure through the State of Ohio Counselor, Social Worker, and Marriage and Family Therapist Board #J-18808-Ljbffr The Christ Hospital Health Network