Certified Social Worker

Care Coordinator, Social Services

The Care Coordinator, Social Services, plays a vital role on an interdisciplinary healthcare team by providing and coordinating psychosocial care for patients and their families. This role involves conducting comprehensive assessments, facilitating appropriate interventions and service linkages, and identifying and addressing high-risk psychosocial factors that may impact a patient's health and medical care. The Care Coordinator collaborates closely with healthcare professionals and community resources to support holistic, patient-centered care.

Responsibilities

A. Accountability & Productivity:

• Interviews patient and families and identifies and assesses psycho-social issues in order to develop plans to meet their needs.
• Conducts high-risk screening interviews/assessments and continuously updates assessment of referred patients within appropriate timeframe, per policy or grant requirements
• Assesses and evaluates patients to identify psychosocial needs.
• Conducts re-assessments on an on-going basis to identify changes in clinical or social needs that would impact on-going care of discharge plan
• Demonstrates evidence of engaging and maintaining frequency of contact with clients as specified within identified protocols.
• Completes and submits departmental productivity reports, statistics, monitors/indicators and correspondence per established guidelines and timeframes.

B. Case Management:

• Counsels' patients and families to reduce the emotional, psychosocial and financial stresses of illness and enhance their social functioning. Intervenes by providing patients and families with support and resources.
• Assist patients and families to understand and access available financial, medical and community resources
• Provides counseling/crisis intervention to enhance social functioning and coping mechanisms of patients and families
• Identifies and maintains current information on community resources
• Identifies and establishes relationships with community agencies and services
• Evidence of identification of concerns/barriers and works towards the resolution through timely follow-up for all identified concerns and service provision
• Coordinates and provides information regarding medical issues including adherence, risk reduction and primary and secondary education

C. Service Coordination:

• Implement services for our patients according to the assessment and reassessment following regulatory guidelines.
• Develops care plan with patient/family/significant other, physician, other interdisciplinary and team members. Demonstrates understanding and follow through of all DVAP medical protocols. Acquires appropriate contact information.
• Coordinates and assists in securing needed services, including transportation, access to medication and other community resources.
• Actions demonstrate understanding of available resources to promote cost effective health planning for patients and the organization.
• Actions demonstrate completion and documentation of all activities, including all (Home Visits, Face to Face visits) contact with clients within requisite timeframes as specified by policy.

D. Documentation:

• Compiles, records and maintains the documentation for care coordination intervention, departmental statistics and performance improvement monitors/indicators in a complete, organized, accurate and timely manner in the electronic data system.
• Documentation is completed in the electronic data system and is concurrent and timely.
• Documentation reflects assessment and on-going reassessment of bio-psychosocial needs, care plan and updates with each review, per required guidelines, referrals to physician, etc.
• Completes social services documentation according to the departmental policy, Federal and State regulations and grant guidelines.
• Accurate and current information is maintained in the family record to include the psychosocial assessment interview, service, progress notes, interventions, reassessment information and interdisciplinary rounds.
• Activities related to patient referrals and other services are documented on the appropriate forms and charted in a progress note.

E. Communication:

• Documents, establishes and fosters open verbal communication with interdisciplinary healthcare team, patient, family, significant others and community to facilitate optimal patient care and outcomes.
• Works with internal and external resources to negotiate and resolve problems and conflicts within care plan to ensure continuity of care for the patient.
• Communicates to patient/family/significant others on an on-going basis and serves as a patient advocate.
• Documents case plans and interventions in accordance with department policies and procedures to meet regulatory standards.
• Participates in medical staffing as required and communicates critical information to the interdisciplinary healthcare team.

Education: Essential: Bachelor

Education Specialization: Essential: Social Work

Experience: Essential: One Year

Credentials: Essential: Heartsaver CPR AED

AHCA Level II – Required