Social Worker PRN - Prov Care Management - Providence

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.

• The Social Worker will work closely with physicians, bedside nurses, utilization-management specialists and associated clinical professionals to assist patients/families in an acute setting effectively transition to the next level of care
• Abides by and enforces all compliance requirements and policies and performs these responsibilities in an ethical manner consistent with the organization's values: adheres to hospital policies including confidentiality
• Enhances professional growth and development through participation in educational programs
• Requires minimal supervision to adequately perform essential functions
• Utilizes proper body mechanics when performing job duties
• Performs initial discharge planning patient assessment within 24 hours of admission and evaluates the patient's baseline function versus the discharge needs
• Communicates and collaborates with patients, their families, physicians, therapy services, nursing, utilization review nurses and other departments as necessary to formulate an effective discharge plan for the patient
• 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
• Sends referrals to home health, SNF, LTC, LTACH, DME, !
  
  RF and other facilities to facilitate discharge planning; provides information from the electronic medical record to support the medical necessity for such services
• Performs reassessment based upon changes in the patient's condition or pt.lfamily needs
• Ensures continuity of patient care by acting as a resource for patient information
• Upon finalizing the discharge plan, ensures patient has the medication needed, transportation to home, and all necessary equipment is in place
• Documents all discharge plans and assessments accordingly based on department policy
• Supports RN CM interdisciplinary patient care rounds or conferences
• Communicates the discharge process as part of the rounds
• Documents avoidable days to assist leadership in capturing performance improvement opportunities
• Establishes both patient and provider goals to determine next steps required to provide the patient with a positive experience and well-established transition of care
• Evaluates inpatient high utilizer patient population (4 or more hospitalizations in 6 months) for any potential risks for readmissions based upon the risk scoring in the electronic medical record
• LSW to evaluate social determinants of health as well as differences within initial assessment and discharge needs
• Based upon findings, provide resources to help reduce the possibility of readmission
• If readmitted, perform readmission assessment within 24 hours of admission; should opportunities present that would help reduce further readmissions, the LSW will place appropriate referrals for further services
• Collaborate with outside agencies and community case management programs to formulate individual plans of care to reduce readmissions
• Functions as a team player and leader in cooperative spirit inter and Intra departmentally
• Demonstrates the ability to provide competent patient care to implement an effective discharge plan to the following patient populations: neonate, pediatric, adolescent, adult, and geriatrics
• Performs discharge planning assessment upon admission on all self-pay, patients and any other patients identified by a healthcare team member as having specific discharge needs
• Provides discharge planning by:
  • Assisting with obtaining medications
  • Finding nursing home placement
  • Finding rehabilitation placement
  • Assisting with Veteran's Administration patients transfers and discharge needs
  • Referring to mental health facilities
  • Assisting with transportation
  • Probating commitments
  • Assisting with arranging home health
  • Assisting with arranging DME
  • Assisting with arranging hospice
  • Assisting with arranging tong term care placement and transfers
• Collaborating with physicians, UR staff, and other…