Responsible for assessing, discharge planning, and intervening on behalf of patients and families regarding health status, personal, social, emotional and economic issues as part of the continuum of care delivery.
Manages processes effectively in regard to employee/ patient safety.
Maintains all required records, reports, statistics, logs, files and other documents as required.
Promotes a culture of process improvement by establishing unit/department based programs that supports the system’s process improvement goals.
Actively participates on system-wide or hospital-based teams.
Roles Specific Responsibilities
Performs concurrent patient assessment related to appropriateness of the level of care, diagnosis, procedures performed, and intervenes to expedite the patient’s plan of care.
Provides consultations to medical staff and other members of the multi-disciplinary team regarding the impact of socio-emotional factors on the patient's illness, and intervenes to expedite the plan of care.
Provides and documents discharge planning services in a professional, collaborative and timely manner to optimize meeting patients' post-hospital discharge care needs.
Collaborates with the interdisciplinary team to assess, monitor, implement and evaluate patient care needs during the hospital stay in order to smoothly transition the patient to the next level of care;
Utilizes evidence-based practice standards to guide the evaluation of care, length of stay, medical necessity of services, and appropriate use of organizational and patient centered resources. Medically complex setting determinations may require consultation with the R.N. Case Manager.
Intervenes on behalf of patients with specific needs not limited to abuse, neglect, mental health issues, end of life issues, ethical concerns, legal matters, financial concerns, and challenges in family dynamics;
Facilitates and acts as a resource to other members of the healthcare team for functions to include but not limited to guardianship proceedings, adoption, advance directive planning, and emergency detentions.
Develops and maintains collaborative relationships with organizations in the community that facilitate provision of appropriate care during the hospital stay and facilitate efficient and effective planning for continued care for the patient:
Collaborates with necessary staff and post-discharge care providers to assure a safe and effective discharge plan; Facilitates care conferences with patient and/or family support structure to foster decision making that promotes patient advocacy.
Supports Service Excellence initiatives contributing to the organization becoming a top performer in quality care, patient safety and patient satisfaction strategies: Understands and applies techniques to support the provision of population based appropriate care utilizing Joint Commission standards, CMS Core Measure requirements, and other best practices.
Acts as an expert resource to the interdisciplinary healthcare team, physicians and other leaders:
Participates in interdisciplinary team meetings in a collaborative manner resulting in achievement of best patient outcomes; Participates actively in departmental and hospital wide teams, committees, or other improvement initiatives.LEAD: Provide supervision as required to LSW on teamLEAD: Maintain documentation of the contact hours, provided to manager and employeeLEAD: Responsible for annual skill competency of social work teamLEAD: Assists with orientation for all new social work case managers, serves as mentor for new social work case managers after orientation
LEAD: Works closely with Case Management Leadership to determine continuing education needs of social work team
LEAD: Encourage growth and collaboration throughout system to social work team
LEAD: Arrange and facilitate weekly follow up with LSW obtaining contact hours for LCSW requirements.
LEAD: Provide ongoing education and follow up to social work team