Description

RESPONSIBLE FOR:
The Social Worker strives to promote patient and family wellness, improved care outcomes, access to appropriate hospital and community resources, and manages, supports and develops comprehensive transitional care plans for patients with complex and psychosocial needs in Inpatient and Emergency Department (ED) environments.
1. Assesses, evaluates, plans and coordinates community services
2. Advocates for services to meet the specific patients / family complex needs
3. Conducts high risk assessments within timeline required by departmental and regulatory guidelines
4. Coordinates with Care Manager daily
5. Conducts psychosocial assessments
6. Provides patients / family members with Community Resources
7. Coordinates the transition to post-acute care services (Hospice, Home Health, Skilled Nursing Facility, etc.)
8. Coordinates as needed with other members of the care team
9. Organizes family meetings and/ team conferences
10. Works with the treatment team to provide solutions for complex cases (i.e. Behavioral Health and/or barriers to discharge)
11. Identifies high risk patients based on standardized criteria
12. Coordinates appropriate reporting to legal agencies as needed with respect to abuse and neglect
13. Facilitates the coordination of financial assistance as needed
14. Identifies and documents quality variances and/or barriers to discharge
15. Provides post discharge follow-up as appropriate to ensure continuity of care/services
16. Participates in PHC readmission management initiatives