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The Care Coordination Social Worker Sr. (SW Sr ) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. Serves as an expert resource for complex patient and situations and serves as a consultant to the other care team members regarding patient's psychosocial and resource needs.
In conjunction with the patient and physician, the SW Sr will assess, coordinate, and implement a timely, safe patient discharge plan to the next appropriate level of care. Overall, the role integrates and coordinates the patients transitional care plan into their individualized discharge plans based on needs and resources available. Specific functions within this role include: Responsible for providing psychosocial assessments for patients to include timely and appropriate planning to advance the discharge plan.
Assists in relaying information about community-based service offerings (e.g.-indigent care referrals and assistance, specialty care or post-acute placements, elder assistance, etc.) and offers guidance to patients/families to assist with multi-system factors that affect patient/family psychosocial dynamics. Serves as a specialist on issues related to psychosocial and discharge needs, end of life care planning, resource needs, etc.
Will provide resource information necessary to aid patient/families in decision making up to and including support for end of life. Will partner and offer feedback to the RN Care Coordinator concerning complex social determinants of health issues, situational dynamics, and social needs. Will participate in orientation and precepting of new social work hires (as needed).
The SW Sr will mentor other social workers in case reviews and discussion of difficult situations, to include, but not limited to assessing suicidal ideation, bereavement risk, social determinants of health, cultural or language barriers, abuse cases (both children and adult), along with many other scenarios. May have other duties assigned. Core Responsibilities and
Complex Disposition Planning * Implements discharge planning and provides resource information in a timely and efficient manner for complex patients. * Identifies and documents barriers for timely disposition. * Understands eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge. * Responds to referrals for patient assistance from RN Care Coordinators, physicians and the care team. * Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge. * Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care. * Provides financial needs assessment for patients requiring assistance for follow-up care throughout the continuum. * Advocates and partners with the patient and family to empower them to make autonomous health care decisions keeping the patient and their wishes at the center of all discharge planning. * Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care. * Allows for any cultural or religious beliefs in providing service and continuity of care.
Assessment * Based on preliminary screening of patients, initiates assessment of patients psychosocial risk factors and availability of resources to assist upon discharge. * Partners with the PAS, financial counselor, and/ or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements. * Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patients care progression and discharge plans.
Documentation * Initial psychosocial /functional assessment completed and documented in medical record. * Ensure all records are up-to-date and documentation is understandable. * Ensure timely and accurate documentation of progress notes and interactions with patient/family. * Accounts for and indicates all services arranged/delivered in Electronic Health Record. * Track avoidable days and report trends that lead to undesired outcomes.
Precepting/Mentoring * Assist leadership with precepting new hires when needed. * Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care. * Serves as a preceptor and/or mentor for student interns Professional Development and Initiative * Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education. * Supports departmental- based goals which contribute to the success of the organization. * Participates in the development of protocols, procedures and performance improvement as indicated * to optimize patient outcomes.
Performs other duties as assigned Complies with all Wellstar Health System policies, standards of work, and code of conduct. Required Minimum
Bachelors Social Work required or Masters Social Work-Preferred Required Minimum License(s) and Certification(s): All certifications are required upon hire unless otherwise stated. BLS - Basic Life Support or ARC-BLS - Amer Red Cross Basic Life Support or BLS-I - Basic Life Support - Instructor LMSW - Lic Master Social Worker GA or LCSW - Lic Clinical Social Worker GA Additional License(s) and Certification(s): Required Minimum
Minimum 2 years of experience in healthcare in the acute care setting, related field or skilled care environment or community. Required and A background in medical social work in an acute care setting Preferred Required Minimum
Excellent written and verbal communication skill. Must possess maturity, self-confidence, objectivity, and positive attitude. Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment Strong assessment, interview, organizational and problem-solving skills.
Knowledge regarding local, state and federal regulations required. Knowledge of community and state-wide resources and programs. Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care.
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