Medical Social Worker

BRIEF SUMMARY The Medical Social Worker is responsible for coordinating the discharge planning assessment and needs of patients and their families, as well as to provide supportive counseling, psychosocial assessment and interventions for patients with complex psychiatric, social, medical and financial needs. The Clinical Social Worker assists the interdisciplinary team in order to help the patient and families cope with hospitalization, illness, diagnosis, treatment, and other issues as they prevent a barrier to efficient patient throughput and quality outcomes. The Medical Social Worker will intervene with patients based on referral from the Care Coordinator and established high risk criteria.


Job Responsibilities:

Discharge Planning and Placement

1. Responds to requests for discharge planning on a timely basis.
2. Conducts a discharge planning needs assessment and develops a discharge plan in conjunction with the RN care coordinator and the interdisciplinary team to meet desired goals for the next step in the continuum.
3. Communicates to patient/family, care coordinator and interdisciplinary team members the discharge options and plans for complex patients. Communicates to patients their choices regarding discharge plans, and respects these choices as defined by federal, state and regulatory requirements.
4. Keeps the care coordinator and team updated as to the status of the discharge plans. Re-evaluates and revises the discharge plan as additional information is acquired and keeps patient/family and team informed to changes in the plan.
5. Works with care coordinator to obtain insurance approval for post acute services. Maintains current knowledge and awareness of payer/reimbursement practices.
6. Coordinates the actual discharge plan, including transportation.
7. Coordinates utilization of patient and community resources to facilitate achievement of safe and effective discharge plan and accomplishment of goals.
8. Finalizes all discharge planning arrangements within 24hours of discharge.
9. Ensures that any information that would be helpful, as appropriate, to facilitate continuity of care post-discharge, are communicated to post acute provider via discharge paperwork or via phone as per departmental documentation guidelines.

1. Develop reference materials for nursing staff to ensure safe discharge placement during off hours.
2. Follows up on discharge planning issues identified by nursing staff during off hours.
3. Develop strong relationships with community health resources to ensure appropriate patient access after discharge. Completes timely referrals to post discharge providers, ensuring efficient patient flow and adherence to federal and regulatory requirements.
4. Works with senior leaders to remove barriers to safe discharge of unfunded patients.

Develops, maintains and provides community resource information to patients.

1. Documents according to policy.
2. Social Worker who provides care to Joint Replacement patients will receive 1 hour of ortho/joint replacement specific education yearly.

Crisis Intervention and short term psychosocial counseling

1. Screens patients, upon referral or according to high risk criteria for psychosocial needs. Conducts psychosocial assessment when indicated to identify emotional, social and environmental issues impacting quality outcomes and efficient patient throughput.
2. Provides crisis intervention, supportive counseling and advocacy to assist patients and/or family with adjustment associated with illness, hospitalization and/or alternative care placement. Facilitates the decision making process in complex cases.
3. Seeks appropriate consultation and referral services for psychosocial intervention (both during hospitalization and as follow-up).
4. Communicates findings to care coordinator and other members of the interdisciplinary team and intervenes as appropriate in order to ensure a proactive approach to crisis intervention and efficient patient throughput.
5. Documents according to policy.

Patient Advocacy

1. Helps patient/family understand, accept and follow medical recommendations within the context of self-determination.
2. Helps patients understand their rights in regards to patient choice, medical treatment, advanced directives and other related issues.
3. Initiates appropriate referrals to the Ethics Committee, Physician Advisor, Risk Management or Legal Services, as appropriate.
4. Facilitates resolution of issues surrounding patient care in a compassionate manner, functioning as a patient advocate.
5. Coordinates and ensures reporting of mandated child and elder abuse/neglect as required by law.
6. Ensures advance directives are in place and honored according to patient wishes.
7. Facilitates resource acquisition for the unfunded patient, as available.

Patient Education:

1. Provides education to patient and families around issues related to adaptation to the patient's diagnosis, illness, treatment, and discharge plan and/or life situation.
2. Participates in multi-disciplinary team meetings and provides leadership in representing the social work perspective.
3. Serves as a resource to members of the interdisciplinary team and patient/family regarding coverage issues, discharge options and community resources
4. Documents according to policy.

Interpersonal Relationships and Job Performance:

1. Employs a high degree of skill in all oral and written communications and personal interactions and demonstrates collaborative working relationships.
2. Uses appropriate resources and methods to resolve conflict with others.
3. Meets assigned deadlines and quality standards without reminder from supervisor or others.
4. Maintains a calm, rational, professional demeanor when dealing with others, even in situations involving conflict or crisis.
5. Maintains absolute adherence to hospital and departmental policies and practices regarding confidentiality and patient's rights.
6. Demonstrates knowledge and support of the hospital's mission and values.
7. Maintains clinical competency and current knowledge of regulatory and payer requirements to perform job responsibilities.
8. Comply with all applicable state and federal regulations as well as The DNV requirements regarding the SW process.
9. Acts as resource to staff for issues related to Social Work processes
10. Act as resource to the staff for regulatory issues regarding the discharge-planning and psychosocial processes.

Education, Knowledge, Skills, Abilities and Experience:

Masters in Social Work, At least two years of clinical experience as a Social Worker, preferably in the acute care setting. Strong critical thinking skills Ability to establish and maintain collaborative and effective working relationships. Able to assert needs to patients, families, physicians and other members of the interdisciplinary team while maintaining established rapport and relationships. Ability to communicate both verbally and in written forms.

Licenses and Certifications:

BLS/CPR (American Heart Association)