Social Worker, Medical Social Worker

Social Worker – Hospital / Inpatient Discharge Planning

Provides therapeutic intervention and social work services to patients and their families to enhance comprehensive, integrated, and uninterrupted care in the hospital and ensure continuity of care in the community.

Responsibilities include, but are not limited to:

• Assess patients' psychosocial situations in relation to their medical needs and plan appropriate interventions and treatment goals to improve patient and family functioning.
• Interview patients, family members, and/or significant others identified through case finding or referrals to assess social work needs and/or interventions related to social determinants of health.
• Participate in multidisciplinary rounds and provide input regarding the patient's psychosocial context.
• Function as a resource and advocate for patients and families in discussions involving advance care planning.
• Provide psychosocial support to patients and families during adjustment to illness and life changes, including preventive, protective, and supportive services for patients who are in or threatened by situations detrimental to their well-being.
• Collaborate with the healthcare team regarding in-hospital needs and post-hospital care; maintain current knowledge of available psychosocial service programs and provide relevant information to patients, families, staff, and community organizations.
• Coordinate and maintain a viable psychosocial discharge planning program for the assigned service area, including appropriate after-care services such as:
• Long-term/custodial care
• Acute rehabilitation and sub-acute rehabilitation/Skilled Nursing Facilities (SNF)
• LTAC, dialysis, and hospice
• Homelessness solutions and community resources
• Ensure continuity of care through comprehensive and appropriate discharge planning with patients, families, and/or significant others.
• Document psychosocial assessments, individual contacts, family interventions, and discharge planning in accordance with department policies and procedures and applicable state, federal, and Joint Commission requirements.
• Develop and maintain a social service network with city, state, and other governmental services to assist patients with resources such as food stamps, financial assistance, transitional housing, benefits, entitlements, and other services. Participate in program planning and improvement, maintain confidentiality, and perform other duties as assigned.

Excellent communication, negotiation, and conflict-resolution skills.

Knowledge of trends and advances in clinical practice and healthcare informatics, as well as new developments and innovations in hardware and software technology.

Knowledge of relevant state and regulatory standards related to social work.

Experience with rapid-cycle change and/or clinical performance improvement preferred.

The physical demands described here are representative of those that must be met by an