Social Worker (MSW) - Transitions of Care/PRN (Scheduled As Needed)

Job Summary

The purpose of a case manager is to promote an optimal level of social/emotional functioning and to enable wellness patients to appropriately utilize health care and other services to achieve their optimal level of health. The case manager recognizes that the relationship between psychosocial factors and illness influence the patient’s recovery. Through provision of patient centered assessments and brokering for post-acute services the case manager identifies variables the can or will effect optimal transition from the hospital. Collaboration with the interdisciplinary team, the patient, loved ones, and through mobilization of community services personal and professional resources the work of the case manager can substantially reduce hospital and patient cost, decrease readmissions and improve the quality of life for patients.

Job Description

Essential Responsibilities:

*Note: While these are considered essential responsibilities of the position this is not a comprehensive inventory of all duties and does not take into considerations accommodations that may be required as situations arise.

1. Discharge screening, evaluation, development and implementation of discharge plans with focus on those with complex needs.

• 2. Reassessment of discharge plan and monitoring for changes in condition
• 3. Patient advocacy with support persons and healthcare team if needed

4. Interventions and support with family stress and emotional needs as it related to making appropriate healthcare decisions.

• 5. Crisis intervention/adjustment to illness/bereavement
• 6. Resource brokering (SNF, home care, hospice, infusion, LTAC, DME, etc)
• 7. System integration/continuity of care and interdisciplinary collaboration
• 8. Adoptions

9. Follow up calls for per Transitions of Care Discharge Policy. Ability to assess patient care needs over the phone and apply interventions.

10. Provision of resources to patients prior to or after admission to facilitate an effective discharge plan as patient care needs change and emerge.

11. Chemical dependency and mental health assessments and referral to treatment

12. Readmission assessments and trending.

13. Provision of Medicare Notification Letters.

14. Assistance with resolutions of financial concerns including linking to eligible programs and hospital assistance programs

15. Abuse (adult, child, sexual, domestic violence) assessments and referrals.

16. Assessment of Social Determinants of Health and ability to understand the manner in which a variety of government programs and social service agencies are organized and function and an ability to assist individuals with accessing those programs and services.

17. Provides information and execution of advance directives.

18. Participation in departmental, hospital and community meetings and initiatives relative to departmental scope as assigned.

19. Complete psychosocial assessments for patients with medical, behavioral health, substance use for the development of an appropriate treatment/crisis plan

• 20. Provides crisis intervention and support services to psychiatric patient’s of all ages
• 21. Assist in the execution and completion of Emergency Detentions Orders, ensuring legal accuracy

22. Performing duties in a variety of settings, including but not limited to the Emergency Department, inpatient, CBC, ICU, outpatient and other hospital areas.

23. Responsibilities require travel between facilities

24. Provides psychiatric consultation to Hendricks Regional Health Emergency Rooms and Medical/Surgical Units2Serve as the point person for cases involving child abuse/neglect, elder abuse/neglect, domestic violence, and other protective issues

• 25. Interpret and communicate complex patient and family needs, serving as a role model for caring practices
• 26. Support complex discharge planning and coordination of care transitions

27. Collaborate with healthcare team members to facilitate safe, timely, and effective care and discharge planning

The functions of this position are not limited to what has been listed; other tasks may be performed as assigned.

Education and Experience Required

A Master of Social Work degree (M. S. W.) from a school with an accredited social work program and either:

1) educational emphasis on health care, including a field placement in a hospital social service department or other health care agency OR

• 2) previous work experience in a hospital social service department or other health care setting.
• 3) Behavioral health experience preferred

Mandatory Licensure/Certifications

Valid and active Indiana Social Work licensure required.

Work Shift

4th Shift (United States of America)

Scheduled Weekly Hours

0