Synergy Alliance Group

REQUIRED EDUCATION, EXPERIENCE AND CERTIFICATION/LICENSURE

Masters Degree in Social Work or Psychology from an accredited graduate school preferred

Current State of Michigan/Florida Master’s Degree Social Work License or Limited License Social Work degree

Interpersonal skills necessary in order to obtain information provide counseling and interact effectively with patients and families and SJMHS colleagues

Analytic skills necessary in order to assess patients’ needs, develop associated discharge planning and provide sound advice and guidance

Ability to concentrate and pay close attention to detail for up to 90% of work

Must be mobile enough to move between nursing units and outpatient settings and in/out of patient rooms and offices

Demonstrates consistently high levels of clinical competence with demonstrated ability to provide clinical interventions at the individual, family, group, system and community level

Ability to function effectively within a multi-disciplinary team

Demonstrated ability to successfully provide quality patient care considering age specific, developmental and cultural needs

Demonstrates unit/area competencies

Ability to exercise empathy and compassion when working with members and responsible parties

RN, LPC, LMSW

Case management: 1 year (Preferred)

Clinical Social Worker (Preferred)

Responsibilities

Assists patients and families in coping with problems associated with severe and long-term illnesses

Conducts patient and family interviews, prepares psychosocial assessments, develops treatment plans, provides counseling and crisis intervention, and directs patients to designated community agencies and resources

Provides consultation to patient treatment team members and participates in developing new patient care programs

Required to provide individual, family, and/or group treatment as part of interdisciplinary treatment plan

Provides quality patient care considering age specific, developmental, cultural, spiritual, diversity, and/or other special needs or circumstances through competent clinical practices

Functions as a member of the interdisciplinary care management team

Interviews patients and families to obtain psychosocial data

Evaluates and gather data from the patient, family, outpatient supports and other collateral sources (including the primary care provider) regarding plan of treatment and available resources, and develops an appropriate intervention plan

Provides a variety of direct services and clinical interventions in order to provide continuity of care and to help patients and families resolve socio-emotional problems associated with adjustment to illness, resource needs, mental health problems and a variety of life events and transitions

Coordinates care of identified high-risk patient population across continuum, specifically addressing psychosocial issues

In collaboration with patient, family a primary care provider, develops plan to address and manage issues which influence health care utilization including services for home as well as facilitates hospital-to-hospital transfers, hospice, extended care facility, acute rehabilitation and long term care facility placement

Refers patients to designated community agencies or resources for financial assistance, counseling, mental health and substance abuse follow up, and other support services

Conducts continuity of care planning for assessing needs support services for home as well as facilitates hospital to hospital transfers, hospice, extended care facility, acute rehabilitation and long term care facility placement

Provides ongoing assessment of educational needs of patient/family in collaboration with interdisciplinary staff and develops appropriate interventions and programs in response and maintains good working relationships with community resources

Demonstrates ability to make appropriate and useful changes in the patient’s treatment plan when problems persist and recognizes when discharge and/or transfer of care is in the best interest of the patient

Advocates, educates, and facilitates resolution of patient rights, ethical and legal issues such as advance directives, end of life decisions, guardianship, etc

Systematically identifies and addresses barriers and fragmentation of care while proactively/collaboratively problem solving to find solutions

Documents social work assessment data and progress notes for each patient including nature of psycho-social concerns, patient and family supports and needs, and intervention plan in accordance with department documentation standards

Provides consultation to other patient treatment team members regarding socio-emotional factors that affect patient’s condition, treatment plan and recovery

Regularly communicates with other departmental and community agency personnel to coordinate social work functions and other services, exchange patient information, and ensure continuity of care

Utilizes pertinent population data to identify trends, potential areas of targeted intervention

Uses metrics to establish measurable goals and monitor outcomes

Uses professional expertise to advance policies and practices that improve access to care, ensure timely follow-up care and supports the delivery of evidence-based clinical management

In conjunction with identified leadership, develops, implements and monitors clinical quality improvement processes within a specific population and/or program

Regularly prepares and presents written reports that track, monitor and measure outcomes of interventions to address patient/population needs and identify and remove barriers

Provides Social Worker leadership in related committees, task forces and work groups with a focus on improved health outcomes for the populations served

Serves as a change-agent and resource to foster adoption of process/service/system improvement initiatives at various points of services

Serves as an advisory role for social policies in community development programs

Understands legal issues that affect treatment, including but not limited to: child custody, divorce laws, child/adult abuse, duty to warn, recipient rights policies and procedures, alternative treatment orders (ATO’s), and the commitment of inpatient hospitalization

Maintains knowledge of current trends and developments in the field

Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of co-workers, and to report all preventable hazards and unsafe practices immediately to management

Reports all preventable hazards and unsafe practices including near misses and actual errors either to management or using the anonymous reporting system (PEERS)

Assists other Health Center department and staff develop and implement new patient care programs and modify existing programs to meet the needs of patients and families

Conducts educational and orientation programs for staff, students, and other Health System employees

Attends and participates in departmental, Health System, and community committees and meetings as necessary.​