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JOB SUMMARY:

The Licensed Clinical Social Worker works in collaboration with the patient and clinical staff to provide an efficient and compliant service following patients before and after discharge. Demonstrates commitment to the philosophy and objectives of discharge planning, community - and population health management, palliative care, and readmission reduction efforts. The Social Worker provides appropriate healthcare services, resource identification, and follow up to patients during admission and post-discharge as indicated by the patient, interdisciplinary staff, social work assessment, and/or facility policy.

DESCRIPTION OF DUTIES:

1. Contributes to the development and implementation of a goal-directed, patient centered plan of care through an interdisciplinary team process that is prioritized and based on determined medical diagnosis, risk assessment, patient needs, and expected patient outcomes.

2. Comprehensively assesses and documents patients' goals as well as their psychosocial, biophysical, environmental, economic/financial, and discharge planning needs.

3. If needed, procures services and resources, serving as an advocate for patients and families.

4. Communicates patient needs to appropriate professionals (i.e., nurse, clinical pharmacist, diabetes educator, dietician) and follows up.

5. Develops and documents a discharge plan through collaboration with the interdisciplinary team. Ensures that all activities to facilitate and coordinate the plan are being implemented and that the plan is continuously modified based on the patient's changing needs.

6. Communicates with nurses, advanced practitioners, physicians, patients, caregivers, and other care team members to facilitate coordination of clinical activities and to enhance the effect of a seamless transition from one level of care to another across the continuum.

7. Seeks out information and resources and uses creative problem solving for complex discharge planning, quality of care, and utilization issues. Explores new resources when the opportunities for the patient are absent or in short supply.

8. Makes appropriate referrals related to discharge planning, continuum of care, abuse, neglect, and/or exploitation with all necessary information to other agencies/resources to ensure continuity of care and to develop and improve communication with all referral sources.

9. Follows up with high-risk patients following discharge whenever feasible.

10. When indicated, provides supportive counseling concerning issues of stress, chronic illness, grief and loss.

11. Confirms doctor's treatment plan and intended goals with patient and caregiver.

12. Confers with healthcare team members to identify patients in need of intensive post-acute/SNF (Skilled Nursing Facility) services.

13. Confirms probable post-acute/SNF (Skilled Nursing Facility) needs through supplemental patient assessments.

14. Collaborates with the physician, advanced practitioners, nurses, patient, caregivers and other team members to develop a transition plan appropriate to the patient's needs and financial capabilities.

15. Determines the patient's eligibility for post-acute/SNF (Skilled Nursing Facility) services as soon after admission as possible.

16. Studies information available to remain abreast of reimbursement modalities, community resources, review systems, and clinical and legal issues that affect patients and providers of care.

17. Serves as a resource and provides education to patients, physicians, and professional staff on levels of care, discharge planning, quality of care issues, and regulatory concerns.

18. Provides orientation and mentoring to new staff members.

19. Continually evaluates case management services and client outcomes.

20. Works in accordance with applicable state and federal laws and with the unique requirements of reimbursement systems.

21. Is knowledgeable about and acts in accordance with laws and procedures regarding patient confidentiality and release of information, Americans with Disabilities Act, other laws protecting rights, and worker's compensation laws when applicable.

22. Performs other duties, projects, or subjects as assigned by department leadership.

23. Follows Infection Control policies and procedures at all times.

24. Follows Hood Memorial Hospital's Compliance Programs and federal and state regulatory guidelines.

25. Provides on-site supervision to Social Work Interns as assigned by department leadership.

26. Practices in accordance to the Louisiana laws and rules governing social work and adheres to the NASW code of ethics.

27. Other duties as assigned.