Social Worker, Liver Transplant Our Lady of Lourdes

Position: Social Worker, Liver Transplant, Full Time, Virtua Our Lady of Lourdes

Job Summary:

Provides ongoing psychosocial support and navigation services to patients with advanced organ disease, transplant candidates and recipients, mechanical circulatory support candidates and recipients, living donors and caregivers throughout all phases of care. This role spans inpatient and outpatient care settings where the Social Worker collaborates closely with the multidisciplinary care team, ensuring compliance with regulatory documentation standards and is available after hours as needed for emergent evaluations and candidate selection meetings.

The Social Worker also provides counseling, crisis interventions, referral to community agencies, education, bio‑ethics consultation and complex discharge planning coordination. Works with patients, families and caregivers in a compassionate, culturally competent, age‑appropriate manner to facilitate access to transplantation and advanced care services. The Social Worker will participate in multidisciplinary rounds, multidisciplinary selection meetings, as well as outreach initiatives designed to enhance patient and community education about transplantation and advanced care disease services.

Position

Responsibilities Inpatient and Outpatient Psychosocial Assessment and Counseling:

• Uses culturally competent skills to conduct comprehensive psychosocial assessments in both inpatient and outpatient setting addressing patient needs, family dynamics, social histories, and financial needs. Interviews family members and others to obtain relevant information required to develop an individualized care plan based on psychosocial assessment, including age and other factors, throughout all phase of care.
• Communicates pertinent psychosocial data to the transplant and advanced organ disease teams and referral sources.
• Provides supportive counseling in collaboration with patients and families as needed through all phases of care and collaborates and refers to the psychiatry or behavioral health team as needed for additional guidance and support.
• Participate in and develop inpatient and community programs that benefit patients, families, and staff. Implements support groups for specified disease processes or biopsychosocial issues to assist community outreach and development.
• Maintains appropriate and complete documentation of the psychosocial assessment in the inpatient and outpatient setting appropriate interventions, plans, and referrals. Follows up on all referrals from the provider for behavioral health, /psychiatry, substance use disorder treatment, end of life supportive care and other biopsychosocial needs. Make appropriate referrals with respect to patient, family, and transitional needs. Provides education on available resources and strategies for utilizing or gaining access to resources.
• Assist patients with advanced care planning and collaborate with teams to facilitate palliative care or hospice consults as clinically indicated.
• Acts as an advocate for patients and families throughout the continuum of care.

Caseload Management and Care Coordination:

• Maintain a cumulative caseload of patients, providing indefinite support unless a patient relocates or expires. Continually assess and identify the need for emotional support due to illness, financial assistance, medication assistance, lodging and other community resources.
• Manage follow-up for each patient, offering continuous check-ins to monitor psychosocial needs and updating care plans accordingly.
• Prioritize and balance the psychosocial needs of all patients based on the acuity and complex needs of the patients in collaboration with the clinical teams.
• Regularly update the team on patient progress and address any new changes that arise across the care continuum.

Navigation and Coordination of Outpatient and Inpatient Services:

• Primary point of contact for patients and families, coordinating resources across the inpatient and outpatient setting and supporting through the phases of care.
• Participates in multidisciplinary team meetings such as case discussions, discharge rounds and chart review, to formulate discharge plans for patients.
• Collaborate closely with multidisciplinary team members, including…