Description: The Social Worker II – Inpatient is responsible for the progression and coordination of care in the delivery of discharge planning and social work services to inpatient and designated outpatient units on a referral basis. The Social Worker II -Inpatient collaborates with other members of the healthcare team to achieve case management department utilization, financial, quality, compliance and satisfaction outcomes for assigned patients.
Typical Duties: Conducts comprehensive psychosocial, functional, financial, healthcare support systems and discharge planning assessments. Conducts patient, family, and/or representative interviews to assess needs and identify individualized discharge plans that takes into consideration the requests of the patient, family and/or representative. Identifies patients who require assistance with eligibility determination for social programs and funding sources and generates referrals as appropriate.
Develops an individualized discharge plan based on the patient’s medical diagnosis, treatment plan, financial resources, psychosocial issues, outpatient healthcare support system, etc. Educates patient, family, and/or representative regarding post-acute options and ensures that the patient’s choices are incorporated into the discharge plan, when possible. Participates in interdisciplinary rounds to facilitate communication and ensure that a comprehensive, coordinated plan of care is developed and implemented.
Provides brief supportive counseling to patients and families exhibiting complex family dynamics that directly impact patient care. Serves as a resource person and provides counseling and intervention related to treatment and end-of-life decisions; advocates for patient and family empowerment and independence to make autonomous health care decisions. Assists with the submission of guardianship applications, coordination of the process for orders of protective custody, and follow up on open APS and CPS cases.
Identifies the appropriate support system, options, and barriers associated with the discharge of the uninsured and undocumented patients while working with available support systems to transition the patient through the continuum of care. Provides education and referral information regarding JPS and community resources. Documents each component of the case management process and related activities in the electronic medical record system according to departmental policies and procedures.
Serves as an educational resource for physicians, nursing staff and others concerning case management strategies essential in meeting the organization’s quality, utilization, financial and customer satisfaction objectives. Assesses for assignment to and makes referrals for a Primary Care Physician that will assist in the assignment of a medical home; generates referrals to the Physician Advisor according to departmental policies and procedures.
Performs other related job duties as assigned. ???