Social Worker, Mary and Elizabeth Hospital

Under the direction of the Manager and/or Director of Care Coordination, the Social Worker performs activities which support the Care Coordination Department. The Social Worker promotes optimal health care outcomes in accordance with the policies, procedures, applicable laws and contracts, philosophy, mission, vision and values of University of Louisville Hospital; assumes responsibility and accountability for the appropriate utilization of facilities and services and serves as a resource to physicians, nurses and ancillary staff.

The social worker provides psychosocial assessment, discharge planning, information and referral services, counseling, and the coordination of services which meet the health-related needs of patients of all ages in an acute care setting. Must be able to adjust work hours depending upon departmental and organizational needs as determined by the director or manager.

Conducts timely patient needs assessment to develop appropriate discharge/care management plan that will result in best possible outcomes; uses social work screening tools and information from multiple interdisciplinary sources to develop an appropriate plan; reassesses plan regularly and revises as needed to ensure continuing appropriateness of plan as patient’s condition and status change Documents all comprehensive social assessment, reassessment, and discharge/care management plan in EMR (Electronic Medical Record) to communicate accurately and comprehensively to other care givers and according to established policies and procedures Coordinates discharge/care management plan by analysis of options, communication with patient, family, treatment team, insurers, and providers to maximize best possible outcomes; works to foster patient engagement in their care and commitment to discharge plan and self-care after hospital discharge Implements discharge/care management plan in compliance with legal and ethical standards, departmental and hospital policies and procedures, and utilizing adequate knowledge of financial reimbursement criteria, provider and resource options, and interpretation of medical data Communicates accurate, complete patient information in a timely manner to patient, family, Patient Care Team and prospective providers to facilitate discharge plan which best meets patient and family needs; encourages and fosters collaboration between care providers to execute effective care plans Provides crisis intervention and patient advocacy to enhance patient and family ability to cope with psycho-social effects of illness/hospitalization; meets with patients and/or family members at the bedside to provide psychosocial support during various stages of disease processes, including death and dying; utilizes social work methods to help patient and family cope with emotionally demanding issues Serves as an advocate on behalf of patients in guardianship, abuse or resource issues; refers cases to the ethics committee for review, as appropriate; Advocates for patient/family needs in a respectful, non-judgmental and confidential manner Identifies risk issues accurately and implements procedures which appropriately address risk concerns (APS, CPS, MIW, duty to warn, etc.) Conducts family conferences routinely, especially for complex family situations or patients with complex or special needs, utilizing social work tools and skills to participate in the resolution and mediation of disagreements and conflicts within family/social systems as they arise in the hospital setting Assesses patient to identify cognitive decline, depression, and other social issues prior to discharge, conducts brief interventions for patients identified as being admitted for illness/injury related to drug/alcohol abuse and referral to substance abuse treatment agencies when patients agree to treatment; works with psychiatric services to identify appropriate inpatient psychiatric hospitalization when indicated for patients with psychiatric emergencies (i.e. – suicide attempts, psychotic episodes) Makes referrals and coordinates services with community-based agencies related to education, mental health issues, potential abuse situations, financial assist or other social/environmental needs of the patients and family; utilizes social work theories and methods to assist in maximizing patient well-being in the long term and preventing psychosocial and logistic complications which could result in readmissions after discharge Actively involved to meet organization metrics and goals to ensure the financial security of the organization Acknowledges, addresses and completes are Consults to Social Worker on respective units in EMR Scheduling

Must be able to adjust work hours depending upon departmental and organizational needs as determined by the director or manager Other Functions: Participates actively in interdisciplinary patient care team meetings, providing leadership to the group as needed; offers information attained from psychosocial assessment to overcome barriers to treatment in the patient’s social environment and support the treatment efficacy provided in the hospital The social worker interacts with physicians, advanced providers, residents, medical students, nursing staff, staff from other departments/services involved in patient care, as well as with providers and community agency representatives; remains accessible to the healthcare team as a resource Participates actively in committees, as assigned, assisting with projects and the work of the committee; seeks to use social work background to bring increased awareness to the organization of the dynamic impacts of patients’ individual psychosocial realities and social environments on physical and mental health Evaluates departmental products, procedures, and services systematically to ensure continuing effectiveness and to identify needed improvements Provides education to co-workers, hospital and medical staff, and the community to provide information about departmental functions, social services-related concepts and services, and community resources Pursues continuing education by participation in departmental or hospital-wide in-service programs, or in classes, workshops, or conferences Supervises graduate social work students, as assigned Maintains compliance with all company policies, procedures and standards of conduct Complies with HIPAA privacy and security requirements to maintain confidentiality at all times Performs other duties as assigned Additional