The Social Worker (MSW or BSW) will ensure patient progression through the continuum of care in an efficient and cost-effective manner. Responsibilities will include utilizing expertise in patient/family assessment incorporating physical, psycho-social, environmental, spiritual, and financial factors to create a sound discharge plan; reducing length of stay and readmissions; utilizing psychosocial assessment skills and crisis intervention techniques to expedite and support healthcare team's work with patient/ family; and collaborating with the RN Case Manager to identify and initiate the most efficient discharge plan to expedite the patient transition to the next appropriate level of care and to reduce length of stay. This position is the organization's expert in assessing and managing the patient's psycho-social needs of hospital patients. The Social Worker educates the health care team and physicians about psycho-social issues and identified patient/family problems as well as recommends strategies to address these issues.

1. Completes a face to face assessment of all new patients in caseload within 24 hours or next business day to identify appropriateness for acute care, level of care and to anticipate high level care planning needs. Screens high risk patients with lace score greater than or equal to 10 to reduce 30 day readmissions.  Consults with attending physicians regarding potential care transition barriers identified as a result of this process.
2. Assumes transition process in collaboration with the multidisciplinary team and patient/family and assists with executing the plans and interventions to facilitate the stay and manage length of stay.
3. Facilitates patient care conferences/complex case conferences proactively as needs are identified to reduce avoidable readmissions and length of stay.
4. Identifies and reports process improvement opportunities by capturing delays in care by documenting avoidable days in MIDAS per guidelines.
5. Provides an Important Message notice and choice on Medicare patients as appropriate.
6. Monitors and facilitates appropriateness of tests/procedures, consultation, treatment plans and resource utilization.
7. Implements the care transition through service referral and assures that the patient is given choice in regard to agencies and services.
8. Maintains contact with the patient, family, RN, physician, and team members to ensure the most cost effective plan of care is being carried out and appropriate in network providers are being utilized.
9. Implements the care transition through service referral and coordination activities. The Social Worker always assures that the patient is given the choice in regard to agencies and services.
10. Provides information about resources and options available in the community and coordinates service delivery. Interprets patient/family needs and provides information concerning the availability and limitation of resources.
11. Maintains functional working relationships with community providers.
12. Identifies and reports process improvement opportunities.
13. Coordinates and collaborates with other healthcare professionals in multi-disciplinary meetings and multi­disciplinary rounds.
14. Provides factual information based on current knowledge, to provide psychosocial support and assist the patient/family in coping with their disease to improve their overall health care management
15. Establishes a comprehensive discharge care transition for inpatients with post-acute care needs. The Social Worker will organize, secure, integrate and modify the resources necessary to meet the goals in the stated care transition. The Social Worker will monitor patient care across the continuum through follow-up with patients, families, and community services. Provides clear and timely information on the patients plan of care to the next provider
16. Documents plan of care and updates /changes in plan of care in the electronic medical record.
17. Educates the patients/family by intervening, negotiating, and promoting their concerns. Problems requiring advocacy may include individual and class inequities or inadequate and non-existent hospital and/or community resources, such as insurance benefits, housing etc.
18. Serves in obtaining legal guardianship, competency determinations, adoption related situations and all cases where Adult or Child abuse is a concern. Is responsible for making sure all legal documents are completed. Collaborates with the Corporate Director and Manager of Case Management as needed.
19. Provides counseling and support as needed. Identifies cases which would benefit from palliative care and elicits palliative consults as needed.

• Maintains pertinent and timely documentation in the Meditech and Midas systems

18. Collects and maintains specific information for department performance improvement initiatives

• Provides psycho-social support as needs dictate. Continuously reviews service area for needs and opportunities.
• Represents DCH, when requested through participation on committees and referrals to community agencies.

21. Attends regularly scheduled department meetings.
22. Participates in professional activities to support the Social Work function.

• Demonstrates skills and knowledge necessary to provide care appropriate to neonatal, pediatric, adolescent, adult and geriatric patients. Including knowledge and growth development, the ability to obtain and interpret information to identify patient needs and to provide the care needed
• Performs assigned work safely, adhering to established departmental safety rules and practices. Reports to supervisor, in a timely manner any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients, visitors

25. Performs other related duties as

• Interacts with patients/families/colleagues with respect, sensitivity and attentiveness to promote teamwork and cooperation.
• Adheres to discharge planning and organizational policies and standards as well as standards from external agencies and regulatory accrediting bodies such as Joint Commission.

28. Maintain confidentiality at all times.
29. Attends mandatory in service programs.

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.
• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

Master's or Bachelor’s degree in Social Work.

Two years post-graduate practice in a healthcare setting preferred

Ability to exercise independent judgment

Demonstrates creativity in use of community based , insurance and financial resources to meet specific patient needs

Ability to relate to patients, families, co-workers, the multi-disciplinary team and community agencies in a professional and

sensitive manner

Ability to problem solve in a proactive, creative manner, using sound judgment based on factual information and clinical

knowledge

Ability to effectively negotiate with internal and external providers of patient care services

Ability to develop leadership skills and to serve as a role model for clinical staff

Proficient in computer skills to support documentation of patient care as well as case finding

Ability to work independently

Excellent interpersonal skills and communication style. Communicates in a clear concise and logical manner in both oral

and written form

Current AL Social Work licensure preferred. 

SCOPE, PURPOSE AND FREQUENCY OF CONTACTS:

Consistent daily contact with patients, families, medical and other professional staff from various hospital departments, community agency representatives, governmental officials

DIRECTION/SUPERVISION RECEIVED:

Reports to Corporate Director Care Coordination

DCH Skill Requirement

Must be able to read, write legibly, speak and comprehend English.

WORKING CONDITIONS

1. Social Workers are on site and available five days a week. 
2. As required, a social worker may be assigned to be on call or work weekends and holidays.
3. Is able to lift at least 20 lbs. 
4. Ability to tolerate prolonged periods of sitting or standing and/or walking;
5. Ability to reach reasonable distances to handle equipment. 
6. Good manual and finger dexterity. 
7. Hearing and vision must be normal or corrected to within normal range. 
8. Good communication skills.
9. Physical presence onsite is essential. Hearing and vision must be normal or corrected to within normal range.  Able to perform the duties with or without reasonable accommodation.