This role ensures accurate and timely data entry into information systems and collaborates with Care Coordinators and the interdisciplinary team to develop and review comprehensive care plans, including discharge planning and psychosocial assessments. Active participation in multidisciplinary rounds or huddles is required to communicate the psychosocial impact on care transitions. The Social Worker monitors progress toward established goals, revising plans as needed based on changes in the patient’s condition. They also assess potential obstacles to reintegration into the community, escalating concerns for resolution. This role upholds Tampa General Hospital’s mission, vision, and values in all professional activities.
Understanding of effective communication and teamwork principles necessary to coordinate care with the healthcare team, ensuring timely and safe service delivery.
Ability to clearly interpret and communicate complex patient and family needs to the healthcare team and model compassionate care practices for other caregivers.
Competence in accessing, mobilizing, and coordinating family and community resources to meet patient and family needs effectively.
Capability to educate patients and families on available resources and care plans, ensuring they are informed and supported throughout the care episode.
Aptitude for evaluating patient and family psychological needs and tailoring interventions to support emotional and functional well-being.
Provide brief crisis counseling and therapeutic interventions to improve healthcare literacy and address social deficits, focusing on frequent healthcare system utilizers. Conduct daily multidisciplinary rounds to support patient outcomes and reduce readmissions.
Facilitate complex discharge planning through clinical social work interventions.
Assess high-risk patients via independent case-finding or referrals and develop short-term treatment plans to achieve patient-directed healthcare goals.
Lead patient and family meetings to address healthcare decisions, discharge planning, and other key outcomes across the care continuum, from birth planning through end of life.
Provide charity and financial resources and advocate for vulnerable populations, including adoptions, foster care, psychiatric referrals, and legal healthcare proxy determinations. Serve as a subject matter expert on abuse, neglect, intimate partner violence, human trafficking, and related issues.
Participate in clinical performance improvement initiatives and research.
Support patients’ transitions through the continuum of care, ensuring timely and effective processes.
Deliver mental and behavioral health services, including crisis intervention, motivational interviewing, and evidence-based assessments with recommendations for ongoing care.
Maintain strong partnerships with community organizations, medical teams, law enforcement, schools, child and adult protective services and other agencies to enhance patient and family services.
