DEPARTMENT: DIALYSIS
F ACILITY: Dialysis
WORK TYPE: Full Time
S HIFT: Daytime
SUMMARY:
The Social Worker intervenes with patients who have complex psychosocial needs, require assistance with eligibility determination for social programs and funding sources and qualify for community assistance from a variety of special funds and agencies. In addition, offer crisis intervention to patients and families with psychosocial needs and coordinates and facilitates the development of a discharge plan of care for high-risk patient populations. This role will receive referrals for individuals from at-risk populations from interdisciplinary team members (including physicians, Case Managers, staff nurses and other members of the care team).
Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the patient served. Must demonstrate knowledge of the principles of growth and development as it relates to the different life cycles.
RESPONSIBILITIES:
* On the basis of preliminary risk screening, assesses patient and family psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope.
- Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability; accesses and mobilizes family/community resources to meet identified needs.
- Provides intervention in cases involving child abuse/neglect, domestic violence, elderly abuse, institutional abuse and sexual assault.
- Serves as a resource person and provides counseling and intervention related to treatment decisions and end-of-life issues.
- Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the health care system.
- Participates in discharge planning activities for complex patients, in order to ensure a timely discharge and to provide appropriate linkage with post-discharge care providers.
- Intervenes as necessary with families exhibiting complex social dynamics that directly impact patient care and discharge processes.
- Provides ongoing and current communications with Physicians, Case Managers, Nursing and other multidisciplinary team members as needed regarding the discharge planning status of all patients as is relevant.
- Assists Case Managers with discharge planning activities as requested.
- Provides consultation to Case Managers when coordination with significant or intensive community resources is necessary to achieve desired treatment outcomes.
- Receives referrals for complex patient problem resolution from Case Managers or care team members.
- Screens and coordinates SNF, NH, LTACH and Rehab facility referrals. Referrals will be made for bed availability in and out of local area. Tracks quality of care issues related to referral facility quality of care and documents according to organizational data collection requirements. When necessary, makes recommendations regarding facilities to be removed from the hospital’s referral resources lists.
- Validates discharge criteria for patient and families and notifies Case Managers of newly-identified resources or change in previously-identified resources.
- Educates patient/family and physician regarding post-acute options and addresses issues of choice.
- Provides intervention in child abuse/neglect, domestic violence, guardianship (temporary/ permanent), foster care, adoption, mental health placement, advance directives, adult/elderly abuse, child protection and sexual assault.
- Ensures safe care to patients adhering to policies, procedures, and standards, within budgetary specifications, including time management, supply management, productivity, and accuracy of practice.
- Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor, and resource to less experienced staff.
- Provides direct supervision of baccalaureate social workers, and MSWs with less than 3 years of hospital experience. Provides mentorship to all levels of social work in current social trends and practice.
- Serves as faculty to the Schools of Social Work to provide education and training sites. Provides direct supervision to all on campus social work students.
- Coordinates the assessment, planning, implementation, and evaluation of social work service clinical care.
- Directs all daily patient/family/caregiver social work service operations, including the establishment and implementation of social work service policies.
- Plans and implements in-service and continuing education programs related to social services to meet the needs of their current job responsibilities.
- Provides leadership in identifying opportunities for additional or improved services to address unmet needs.
- Maintains comprehensive working knowledge of community resources, directing patient/family/caregivers to such resources as appropriate, including financial assistance as indicated. Assists referral sources in accessing community resources.
- Completes psychosocial assessments in the patient’s identified residence within 24 hours of admission and plans interventions based on assessment findings with patients and families to help resolve social or emotional issues.
- Assesses each patient/family/caregiver in compliance with the plan of care.
- Demonstrates ability to adequately assess and any needs related to the care plan.
- Provides guidance to and counsels patients and families to help resolve social or emotional issues associated with the current disease process.
- Contacts family members/caregivers with current discharge plan.
- Completes, prepares, and implements any changes or needs identified by the family.
- Provides assistance with any obstacles in the care plan and initiates proper community resources.
- Fosters cooperative and collaborative efforts among family members/caregivers in sharing responsibility for providing patient care. Provides patient/family/caregiver with information, support and encouragement, lending to empowerment and problem-solving.
- Completes, maintains, and submits accurate and relevant clinical notes regarding patient’s condition and care given. All documentation is completed at the time it is done.
- Cultivates cooperative and collaborative effort among hospice team members, family/caregiver, hospital personnel, and other providers in providing continuity of patient care in a holistic manner.
- Follows hospital policies, standards of and social work practice guidelines, and provides care appropriate to patient age.
- Follows up to ensure patient satisfaction.
- Adapts readily to individual personalities, a wide variety of working conditions, constantly changing schedule and patient status.
- Keeps abreast of pertinent federal, and state regulations and laws and Tift Regional Health System, Inc. (“TRHS”) policies as they presently exist and as they change or are modified.
- Understands and adheres to: TRHS’ compliance standards as they appear in TRHS’s Corporate Compliance Policy, Code of Conduct and Conflict of Interest Policy; and HIPAA and TRHS policies regarding privacy and security of protected health information.
- Demonstrates the ability to perform tasks that meet the age-specific requirements of the persons, patients, vendors, and staff that the employee is charged to interact with as required by the position.
- Offers suggestions on ways to improve operations of department and reduce costs.
- Attends all mandatory education programs.
- Improves self-knowledge through voluntarily attending continuing education/certification classes.
- Maintains required competency levels as identified in written exams, skills checklists, skills labs, annual safety and health requirements as well as service excellence education hours requirements.
- Cross-trains in order to better assist co-workers and to provide maximum efficiency in the department.
- Volunteers/participates on hospital committees, functions, and department projects.
- Manages resources effectively.
- Reports equipment in need of repair in order to extend life of equipment and removes malfunctioning equipment out of service with timely reporting to the appropriate personnel.
- Makes good use of time so as to not create needless overtime.
EDUCATION:
* Master's Degree in Social Work
OTHER INFORMATION:
Certification as a clinical social worker required.
Southwell/Tift Regional Health System, Inc. is an Equal Opportunity Employer.
