Social Worker - 40 hours/week
This position would serve as the social worker case manager of Home Health Patients, St. Marys Acute and St. Marys Clinic.
- Assess patient and family psychosocial needs.
- Develop a plan of care in concert with patient, physicians, nurses and other members of the interdepartmental healthcare team.
- Document patient/family status, observations and process in medical record.
- Educates patient, family and other members of health care team regarding benefits, community resources, referrals for counseling and other pertinent information.
- Link patient/family to appropriate community resources including but not limited to information/referral to sources of financial assistance, transportation, support groups and other community services.
- Educates patients and families on, and assists in preparation of advanced directives.
- Advocate for the patient and family with physicians insurance companies, and community resources to ensure continuity of care.
- Provides information and options during discharge planning based on meeting identified goals of the treatment plan.
- Assist patient/family to achieve an effective transition from hospital to post-hospital care.
- Continually monitors the patient care environment and work behaviors to identify unsafe conditions and behaviors.
- Provides teaching-coaching to ensure patient/family are knowledgeable about care.
- Supports and enhances provider relationship with patients and family by providing care services and professional interpersonal interactions.
- Evaluates whether patient qualifies for additional insurance coverage.If so, has a plan for helping patient to obtain this coverage.
- Documents services in the Electronic Health Record upon completion of the intervention.
- Provides top specific in-service to other members of the healthcare team.
- Establish, promote, and maintain positive relations with community agencies/services.