Social Worker/Discharge Planner

Job Description

Job Description

Job Title: Social Worker

Reports To: Director of Social Services

Status: Non-exempt

Position Summary: The primary purpose of the job position is to assist in planning, organizing, developing, and directing the overall operation of Social Services Department in accordance with current federal, state, and local standards, guidelines, and regulations, our establish policies and procedures, and as may be directed by Social Services Director and/or Administrator, to ensure that the medically related emotional and social needs of residents are met/maintained on an individual basis. Essential Duties and Responsibilities: Works with the resident, family, and other members of the health care team to formulate a discharge plan that provides the resident services in the appropriate post-acute care setting. Gathers and assesses information regarding the resident's physical needs, mental status, family support system, financial resources, and available community and governmental resources. Employs assessment to develop a comprehensive case management plan that will address the needs identified. Determines specific objectives, goals, and measures that are designed to meet the client's needs that have been identified through assessment. The plan will be action- oriented and time-specific including collaboration with utilization management to manage length of stay. Maintains contact with the resident's third-party payors to ensure the most cost-effective plan of care is being carried out and appropriate in network providers are being utilized Provides information about resources and options available in the community and coordinates service delivery. Interprets resident/family needs and provides information concerning the availability and limitations of resources. Educates and addresses concerns with service delivery including service gaps and access issues. Implements discharge plan through service referral and coordination activities. As part of the discharge plan development process, collaborates with other healthcare professionals in multidisciplinary meetings and resident rounds. Screens high-risk residents and consults attending physicians regarding potential discharge planning problems identified as a result of this process. Interviews and assesses referred and high-risk residents to determine the need and desire for social work services. Provides information based on current knowledge, to provide psychosocial support and assist the resident/family in coping with their disease to improve their overall health care management. Provides specific information on how to communicate with staff to better utilize resources and increase understanding of the disease process. In accordance with established clinical guidelines, standards, and pathways, establishes a comprehensive discharge plan for those residents with post-acute care needs. The Social Worker will organize, secure, integrate and modify the resource necessary to meet the goals stated in the discharge plan. The Social Worker will monitor resident care across the continuum through follow-up with residents, families, and community services. Educates the community and the general public regarding various symptoms and consequences related to specific diseases, conditions and hospitalization. This information will also include specifics regarding methods of professional intervention and description of the process of social work intervention in a medical setting. Represents resident/family by intervening, negotiating and promoting their concerns. Functions as consultant/advisor to administration, utilization review, public and private insurance programs when discharge planning or utilization "impasse" situations occur. Keeps administration informed of changes in community, state, and federal policies that impact on the length of stay. Maintains pertinent and timely documentation in resident's medical charts and departmental records. Accurately maintains required departmental statistical data. Collects and maintains specific information required for performance improvement indicators and research projects. Utilizes the department Quality Service Plan to address service issues as needed. Performs resident/family evaluations and histories. Provides psychosocial support through individual, group, or family counseling, as needs dictate. Continuously reviews service area for group support needs and opportunities. Represents Christiana Care, when requested, through participation on community/state boards, committees, panels, court hearings, etc. Attends regularly scheduled staff meetings, i.e., team, divisiona