Social Worker - CW Care Management - Children's and Women's Hospital

Overview

USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community.

USA Health is changing how medical care, education, and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists, and researchers provides the region's most advanced medicine at multiple facilities, campuses, clinics, and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall well-being of our community.

• Performs initial discharge planning assessments in a timely manner from time of patient admission, evaluating baseline function versus anticipated discharge needs.
• Follows Mandatory Reporting guidelines for abuse, neglect, exploitation & collaborates with associated agencies.
• Collaborates & communicates with physicians, bedside nurses, utilization management staff, therapy services, and associated clinical professionals to facilitate effective transitions to the next level of care.
• Participates in interdisciplinary patient care rounds and conferences; communicates discharge plans as part of rounds.
• Establishes and supports patient-centered and provider goals to determine next steps for a positive patient experience and well-coordinated transition of care.
• Reassesses discharge needs based on changes in patient condition or plan of care and discusses updates with patients and families/caregivers.
• Provides the patient and family resources based upon his/ her insurance options and helps them to formulate an individual discharge plan based upon their needs.
• Provides individualized discharge planning by:
• Acting as a resource for patient/family
• Assisting with medication access
• Arranging transportation
• Coordinating durable medical equipment (DME)
• Facilitating home health services
• Arranging hospice care
• Coordinating rehabilitation, skilled nursing, long-term care placement, and facility transfers
• Assisting with Veteran’s Administration and discharge needs
• Referring to mental health facilities
• Supporting probate and commitment processes as appropriate
• Sends referrals to appropriate post-acute agencies to support safe discharge and continuity of care.
• Ensures that, upon finalization of the discharge plan, medications, equipment, and transportation are in place.
• Evaluates social determinants of health and identifies differences between initial assessment findings and discharge needs.
• Provides resources and referrals to address identified barriers and reduce the risk of readmission.
• Performs timely readmission assessments when applicable; initiates referrals and services aimed at preventing future readmissions.
• Collaborates with outside agencies and community case management programs to develop individualized plans of care.
• Documents all assessments, discharge plans, referrals, interventions, and actions performed in the medical record according to department policy.
• Documents avoidable delays to support leadership in identifying performance improvement opportunities.
• Abides by and enforces all compliance requirements and hospital policies, including confidentiality, while performing duties ethically and in alignment with organizational values.
• Performs timely intervention related to discharge planning assessment and consults placed for patients as identified by a healthcare team member having urgent social or discharge planning needs.
• Enhances professional growth and development through participation in educational programs.
• Participates in committees and performance improvement activities, or other quality initiatives as assigned.
• Maintains professional practice in accordance with the National Association of Social Workers (NASW) Code of…