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Work Shift
Day (United States of America)
The Care Coordination Social Worker (CC SW) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. Serves as a key resource for patients and serves as a consultant to the other care team members regarding patient's psychosocial and resource needs. In conjunction with the patient and physician, the CC SW will assess, coordinate, and implement a timely, safe patient discharge plan to the next appropriate level of care. Overall, the role integrates and coordinates the patients transitional care plan into their individualized discharge plans based on needs and resources available.
Specific functions within this role include:
Responsible for providing psychosocial assessments for patients to include timely and appropriate planning to advance the discharge plan.
Assists in relaying information about community-based service offerings (e.g.-indigent care referrals and assistance, specialty care or post-acute placements, elder assistance, etc.) and offers guidance to patients/families to assist with multi-system factors that affect patient/family psychosocial dynamics.
Serves as a specialist on issues related to psychosocial and discharge needs, end of life care planning, resource needs, etc. Will provide resource information necessary to aid patient/families in decision making up to and including support for end of life.
Will partner and offer feedback to the RN Case Manager concerning complex social determinants of health issues, situational dynamics, and social needs.
May have other duties assigned
Disposition Planning
- Implements discharge planning and provides resource information in a timely and efficient manner for patients.
- Identifies and documents barriers for timely disposition.
- Understands eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge.
- Responds to referrals for patient assistance from RN Care Coordinators, physicians and the care team.
- Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge.
- Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care.
- Provides financial needs assessment for patients requiring assistance for follow-up care throughout the continuum.
- Advocates and partners with the patient and family to empower them to make autonomous health care decisions keeping the patient and their wishes at the center of all discharge planning.
- Allows for any cultural or religious beliefs in providing service and continuity of care.
- Participates in the development of protocols, procedures and performance improvement as indicated to optimize patient outcomes.
Disposition Planning
Implements discharge planning and provides resource information in a timely and efficient manner for patients.
Identifies and documents barriers for timely disposition.
Understands eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge.
Responds to referrals for patient assistance from RN Care Coordinators, physicians and the care team.
Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge.
Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care.
Provides financial needs assessment for patients requiring assistance for follow-up care throughout the continuum.
Advocates and partners with the patient and family to empower them to make autonomous health care decisions keeping the patient and their wishes at the center of all discharge planning.
Allows for any cultural or religious beliefs in providing service and continuity of care.
Participates in the development of protocols, procedures and performance improvement as indicated to optimize patient outcomes.
Assessment
- Based on preliminary screening of patients, initiates assessment of patients psychosocial risk factors and availability of resources to assist upon discharge.
- Partners with the PAS, financial counselors and/or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements.
- Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patients care progression and discharge plans.
Documentation
- Initial psychosocial /functional assessment completed and documented in medical record.
- Ensure all records are up-to-date and documentation is clear and concise.
- Ensure timely and accurate documentation of progress notes and interactions with patient/family.
- Accounts for and indicates all services arranged/delivered in Electronic Health Record.
- Track avoidable days and report trends that lead to undesired outcomes.
Assessment
Based on preliminary screening of patients, initiates assessment of patients psychosocial risk factors and availability of resources to assist upon discharge.
Partners with the PAS, financial counselors and/or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements.
Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patients care progression and discharge plans.
Documentation
Initial psychosocial /functional assessment completed and documented in medical record.
Ensure all records are up-to-date and documentation is clear and concise.
Ensure timely and accurate documentation of progress notes and interactions with patient/family.
Accounts for and indicates all services arranged/delivered in Electronic Health Record.
Track avoidable days and report trends that lead to undesired outcomes.
Professional Development and Initiative
- Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.
- Supports departmental-based goals which contribute to the success of the organization.
- Serves as a preceptor and/or mentor for social work students (if appropriate)
Professional Development and Initiative
Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.
Supports departmental-based goals which contribute to the success of the organization.
Serves as a preceptor and/or mentor for social work students (if appropriate)
Performs other duties as assigned
Complies with all Wellstar Health System policies, standards of work, and code of conduct.
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Bachelors Social Work M
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Masters Social Work-Preferred
All certifications are required upon hire unless otherwise stated.
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Basic Life Support or BLS - Instructor
Minimum 1 year of experience in healthcare in the acute care setting, related field or skilled care environment or community or educational internship in care coordination. Required and
A background in medical social work in an acute care setting Preferred
Excellent written and verbal communication skill.
Must possess maturity, self-confidence, objectivity, and positive attitude.
Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment
Strong assessment, interview, organizational and problem-solving skills.
Knowledge regarding local, state and federal regulations required.
Knowledge of community and state-wide resources and programs.
Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care.
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