The Medical Social Worker provides clinical social work services for patients throughout the acute care hospital setting. Primary responsibility is for the inpatient units with the exception of Behavioral Health. Outpatient referrals will be honored whenever possible. Provides support and counseling to patients and families who are dealing with serious health care concerns, educates them about their rights and responsibilities and assists in decisions about health care options and advance directives. Serves as an interface with community service agencies for adoptions, reporting of elder or child abuse, probate court actions and financial assistance. In partnership with the Care Manager, is responsible for arranging the transition of patients to extended care facilities, rehabilitation hospitals or other specialized facilities. Uses independent clinical judgment and works collaboratively with the interdisciplinary team. Communicates, as appropriate, the patient’s clinical condition and care needs. Demonstrates knowledge of the principles of growth and development over the life span and the skills necessary to provide age appropriate care to the patient population served. Professional knowledge and judgment will be utilized when guidelines are unavailable or inappropriate for a given situation. Promotes the profession of social work and professional practice through collegial support and interactions. Is primarily assigned to one hospital, but will be required to provide coverage at the other hospital as needed. Reports to the Manager of Care Management.
- Master’s Degree in Social Work
- State of Connecticut License in Clinical Social Work required
- A least two (2) years related experience, preferably in a medical setting.
- Good analytical, organizational and interpersonal skills.
- The ability to communicate effectively in English, both verbally and in writing is critical.
- Must be able to work collaboratively with other members of the health care team.
- Possesses basic computer skills.
ESSENTIAL DUTIES and RESPONSIBILITES:
1. Manages the transition of care for the patient to the appropriate post-hospital setting. Identifies social and environmental problems which impact on the patient’s ability to return home.
- Works with the Physician Advisor to ensure appropriateness of care, cost-effectiveness and best patient outcomes. Identifies problems with care delivery system that impact on LOS, quality and continuity of care and participates in process improvement.
- Identifies reimbursement factors influencing the choice of post-hospital providers and obtains authorizations as required, either directly or in collaboration with the Care Manager. Educates the patient and family about reimbursement, including out of pocket cost to the patient.
- Performs comprehensive assessments and re-assessments of the patient’s needs including the psychosocial, physical, educational and cultural aspects. Provides education and psychological support to the patient and family. Works with the clinical team to develop and modify the care plan to meet the needs of the patient.
- Collaborates with other disciplines in patient evaluation and treatment and initiates referrals appropriately.
- Initiates discharge planning in a timely fashion, develops and revises individualized discharge plans as indicated by assessment and patient response to treatment. Evaluates overall plan daily for effectiveness. Involves the patient and family in the formulation of goals.
- Demonstrates understanding of level of care criteria and reimbursement factors for home care, rehabilitation, residential treatment and long term care in development of discharge plans. Seeks alternatives to facilitate discharge planning.
- Assists patients and families in decisions about advance directives, including providing information and forms to assist families in stating advance directives. Works with the patient, family and clinical caregivers to facilitate discussion about and decisions for DNR status and medical decision making.
- Provides financial counseling to patients regarding resources for medical or social needs. Is knowledgeable about financial resources and refers patients and families to the appropriate resources.
- Reports evidence of child or elder abuse and neglect as mandated by State statutes. Serves as a resource to others about reporting requirements and processes.
- Facilitates evaluation of competency or capacity for those patients who are identified as unable to participate in medical decision-making. Assists in identifying an individual who will serve as conservator and facilitates the completion of required forms for submission to the probate court. Attends probate hearings as required.
- Assists with adoptions, as requested. Provides support and information to patients and families and is a liaison with adoption agencies. Is knowledgeable about the adoption process and informs nurses and physicians about pertinent policies and regulations.
- Documents a thorough assessment and social work interventions in a timely manner, utilizing the appropriate format. Completes State mandated forms. Provides in a legible format adequate verbal and written information necessary for continuation of care in a post-hospital setting (W-10, MI/MR, etc.) Content reflects an understanding of the treatment goals in the next level of care.
- Demonstrates an ability to be flexible, organized and functional under stressful situations. Utilizes critical thinking skills and sound judgment in priority setting and delegation.
- Practices autonomously, consistent with evidence-based standards. Pursues personal and professional growth and development. Serves as a professional role model and mentor. Provides consultation and educates hospital staff regarding LOS and continuing care resources.