Case Management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost-effective outcomes. Social Workers are experts and vital participants in the care coordination team who empower people to understand and have access to quality, safe, and efficient health care services.
As a member of the Case Management team, the Social Worker focuses on the psycho-social, financial, and transition needs to assist the interdisciplinary team in creating a transition plan which promote optimal outcomes including reducing related and unplanned re-hospitalizations. The Social Worker provides direct intervention on an as-needed basis with infants, children, adolescents, adults and geriatric patients and their families.
RESPONSIBILITIES (ESSENTIAL FUNCTIONS): Conduct an assessment of the patient’s health, physical, functional, behavioral, psychological and social needs including, but not limited to the following: adjustment to medical or health condition; care coordination; mental health status; adjustment/compliance to treatment process; substance usage; child and elder abuse/neglect assessments; domestic violence issues; cognitive status (including guardian issues); and patient/family resources.
Identifies patient discharge needs by establishing a personal rapport with patients and their families. Consults with the physician/provider, Case Management team, and allied health providers for the purpose of assisting them to understand significant social, emotional, and environmental factors related to the patient’s health. Educate patients, their families/caregivers, members of the interdisciplinary team about treatment options, health insurance benefits, psychosocial and financial concerns in order to make timely and informed care-related decisions.
Communicate on an ongoing basis with the patient, their family, health care professionals, support service providers the case management plan of care. Coordinate care interventions, referrals to specialty providers, and community-based support services, consults, and resources during the patient’s transition of care throughout the continuum of care. Provide necessary support for each patient and their family according to health status, personal strengths and weaknesses, emotional state and additional factors.
Provide crisis intervention and supportive short-term counseling to patients/families as necessary to meet immediate psycho-social needs. Provide bereavement counseling as needed. Investigate child or elder abuse or neglect cases and take authorized protective action when necessary.
Provides patient advocacy to patient and family in regards to assisting with decision making by providing education and assistance with: advance directives, guardianship, and medical durable power of attorney. Maintains patient confidence and protects operations by keeping information confidential. Maintains a cooperative relationship among health care teams by communicating information and participating in team problem-solving methods.
Maintain current knowledge of local resources and relevant medical research to prove best possible recommendations to patient. Continually evaluate the value and effectiveness of case management plans of care, resource allocation, and service provision while applying outcome measures reflective of organizational policies and expectations, accreditation standards, and regulatory requirements. Attends and participates in Interdisciplinary Team Meetings.
Delivers Important Message from Medicare to patients as per CMS guidelines. Regular attendance and punctuality for scheduled shifts. Appropriately adapts assessment, treatment, and/or care methods to accommodate the physical, cultural, age-specific, and other developmental needs of each person served.
Maintains professional and technical knowledge through continuing education opportunities including internal and external educational offerings. Must adhere to safety protocols at all times. Per DRH policy, all required conditions of employment must be met and maintained including required vaccinations.
This position requires respirator and fit testing. Required testing will be performed on all team members at risk for exposure to airborne infectious diseases, droplet producing procedures, or any caustic chemicals. Implement DRH Standards of Behavior and exhibit behaviors consistent with DRH core values.
Performs other related duties as assigned.