Provides ongoing psychosocial assessment and treatment planning to patients within a variety of specialty areas in the medical setting. Collaborates with the multidisciplinary team, lending insight and clinical expertise. Coordinates complex discharge plans, new placements, changes in level of care, changes in facilities, rehab, and hospice placement. Utilizes resources to enhance patient independence and community adjustment. Responsible for completion and maintenance of patient’s medical records and submission of patient information as required.
Maintains a clinical caseload of patients.
Participates in daily rounds.
Completes psychosocial assessments on all patients and develops treatment and discharge plans from all referred appropriate patients.
Provides crisis intervention services to patients, families and staff.
Provides individual, family and group counseling to enhance coping skills.
Demonstrates knowledge in providing comprehensive clinical case management services for complex discharge plans, new placements, changes in level of care, changes in facilities, rehab, and hospice including receipt of entitlements, advocacy, referral and linkage with schools, the legal system, hospital-based and community resources. Provides patient and family with information concerning available community resources.
Develops and implements treatment strategies to engage, stabilize support and motivate patients.
Demonstrates ability to follow-up, outreach and coordinate service delivery.
Recognizes, evaluates and develops interventions to address signs of abuse, neglect and domestic violence for all ages and takes the appropriate action including reporting incidents to the proper authorities.
Recognizes, evaluates and develops interventions and/or makes referrals for alcohol/substance abuse cases.
Insures timeliness and documentation of all contacts, interventions and outcomes. Completes required forms and assures that confidentially is maintained at all times.
Effectively delegates tasks to the appropriate skill level.
