Transitional Care Social Worker

Rehab and Transitional Care Center Social Worker

Join us in Caring for the Most Important People on Earth™. We reward hard-working professionals with competitive pay, great benefits, and career growth opportunities.

Provides social work services to patients and families in the rehabilitation and Transitional Care Center setting from admission through discharge. Assesses psychosocial needs, supports adjustment to illness and changes in function, and coordinates discharge planning with the patient, chosen supports and interdisciplinary team. Promotes patient choice, continuity of care and access to services needed for the next level of care.

• St. Ann’s Community Offers:
• Salary range $58k - $66k gross/year
• Full time (37.5hrs/wk.)
• Health, Dental, and Vision
• Tuition Reimbursement, and Scholarship Opportunities
• Employer-paid life insurance
• 403(b) with company contribution
• Catholic school tuition assistance

Job Description

Admission and Psychosocial Assessment

• Welcomes patients and families, explains the social work role and short-term rehabilitation process, and assists with adjustment to the unit.
• Reviews assigned admission information, patient rights, communication preferences and facility procedures; addresses questions and refers concerns to the appropriate department.
• Completes social histories and psychosocial assessments, including prior living arrangements, baseline function, support systems, coping skills, cultural preferences, cognition, mood and available community resources.
• Identifies patient goals, preferred discharge location, caregiver availability and potential barriers to discharge at the start of the stay. Verifies appropriate contacts and decision-making representatives through available documentation.

Care Planning and Patient and Family Support

• Participates in interdisciplinary care planning and rehabilitation rounds with nursing, therapy, medical providers and other team members. Updates psychosocial goals and interventions as patient needs change.
• Coordinates and participates in patient and family meetings to discuss progress, care needs, discharge options and unresolved concerns. Encourages patient participation and involvement of supports chosen by the patient.
• Provides supportive counseling, education and referrals within the employee’s role and training for adjustment, grief, anxiety, caregiver stress and changes in health or independence.
• Communicates psychosocial concerns, mood or cognitive changes, behavioral needs and safety concerns to the appropriate team members; seeks supervisory or clinical consultation when needs exceed the role’s scope.
• Assists patients and families with advance care planning conversations and access to advance directive information; refers clinical, legal or specialized questions to appropriate professionals.
• Advocates for patient rights, privacy, dignity and informed choices. Helps resolve concerns and connects patients and families with the appropriate grievance or support resources.

Discharge Planning and Transitions of Care

• Coordinates individualized discharge planning throughout the stay, using the patient’s goals, current function, home environment, available supports and interdisciplinary recommendations.
• Assesses barriers such as limited caregiver support, housing concerns, transportation, finances, service availability and equipment needs. Communicates barriers promptly and works with the team to identify options.
• Collaborates with therapy and nursing to clarify assistance needs, caregiver training and recommended equipment. Confirms the patient’s and caregivers’ understanding of the proposed plan and their ability to arrange needed support.
• Coordinates referrals to home health agencies, community programs and other providers. Works with the team and vendors on durable medical equipment and supplies, and follows up on referral acceptance and anticipated start dates.
• Assists with referrals and applications for assisted living, long-term care or other settings when return to the prior living arrangement is not feasible or is not the patient’s preference.
• Coordinates transportation and communicates discharge dates and arrangements to the patient, appropriate supports and receiving providers. Collaborates with nursing and medical staff on follow-up appointments, instructions and information needed for continuity of care.
• Explains the social and practical aspects of insurance coverage and discharge planning in coordination with reimbursement staff and the Business Office. Assists with assigned notices and appeal procedures under facility policy; refers coverage determinations and financial questions to appropriate staff.
• Escalates unresolved discharge risks, disagreements or requests to leave against medical advice to the Social Work Manager and clinical team. Documents options discussed, patient preferences and referrals, including protective services when indicated.
• Provides emotional support during transitions, completes assigned discharge documentation and performs post-discharge follow-up according to department procedures.

Documentation and Department Coordination

• Maintains timely, accurate and objective documentation in PointClickCare or the designated electronic health record, including assessments, interventions, care plans, family communication, referrals and discharge arrangements.
• Completes assigned MDS interviews, assessments and related documentation within applicable timeframes and training requirements; communicates significant findings to the interdisciplinary team.
• Prioritizes a changing rehabilitation caseload and time-sensitive discharge needs. Provides clear handoffs and follows up on pending services, referrals and unresolved concerns.
• Collaborates with other disciplines and community agencies to connect patients and families with benefit information and assistance with health-related forms, including Medicaid resources when appropriate.
• Participates in quality improvement, required education and departmental meetings. Assists with staff or student orientation and patient or family education as assigned.
• Provides rotating weekend social work coverage and assigned evening or weekend on-call coverage in accordance with department scheduling and facility policy.
• Performs other related duties as assigned by the Social Work Manager.

Candidate Requirements

• Bachelor’s degree in social work (BSW), gerontology or equivalent, with two years of related experience and/or training, or an equivalent combination of education and experience. NYS licensure preferred.
• Social work experience in short-term rehabilitation, transitional care or a skilled nursing facility is preferred, particularly discharge planning and coordination of community services.
• PointClickCare experience is preferred.
• Ability to communicate clearly with patients, families and interdisciplinary team members; lead care planning discussions; and respond professionally to concerns.

Join us in Caring for the Most Important People on Earth™

The employment policy of St. Ann’s Community is to provide equal opportunity to all persons. Our company, therefore, has made a commitment to equal employment opportunity through a positive and continuing Affirmative Action Program. No employee or applicant for employment will be discriminated against because of race, color, religion, sex, national origin, age, disability, veteran status or any other Federal or State legally protected classes.