OB Social Worker LMSW - Care Management

OB Social Worker LMSW – Care Management

The Social Worker is responsible for creating outcomes for the patient and family by managing complex psychosocial and economic co‑morbidities. Provides education and consultation regarding resources, collaborates to develop a discharge plan and facilitates and monitors its implementation. Assists patient/family adjust to and cope with illness, diagnosis, treatment options, and prognosis. Through advanced practice skills mobilizes resources to reduce risk, serves as a liaison between the hospital and the community.

In addition, offers crisis interventions to patient/family. Strives for superior performance by consistently providing a product of service to leadership and staff that is recognized as ultimately contributing to the patient and family experience. As a customer‑focused Memorial Healthcare team member, he/she must be accessible, flexible, knowledgeable, and responsive.

RESPONSIBLE TO:
Director of Hospital Throughput, Associate Manager of Social Work

WORKERS SUPERVISED:
None

INTERRELATIONSHIPS:
Case management department staff; other hospital departments;
Medical staff; patients; families; external agencies

• Psychosocial Assessment and Interventions
• On the basis of preliminary risk screening, assess patient and family psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness, and ability to cope.
• Intervene with patients and families regarding emotional, social and financial consequences of illness and/or disability; access and mobilize family/community resources to meet identified needs.
• Provide intervention in cases involving child abuse/neglect, domestic violence, elder abuse, institutional abuse, and sexual assault.
• Serve as a resource person and provide counseling and intervention related to treatment decisions and end‑of‑life issues.
• Discharge Planning
• Participate in discharge planning activities for complex patients to ensure a timely discharge and to provide appropriate linkage with post‑discharge care providers.
• Deal with families exhibiting complex family dynamics that directly impact patient care and discharge.
• Communicate with the healthcare team regarding the discharge planning status of all patients referred by them.
• Assist RN Case Managers or appropriate team members with discharge planning activities as requested.
• Provide consultation to RN Case Manager or appropriate team members when coordination with significant or intensive community resources is necessary to achieve desired treatment outcomes.
• Receive referrals for complex patient problem resolution from RN Case Managers or care team members.
• Screen and coordinate referrals to the next level of care, SNF, LTAC, Hospice and Rehab; validate discharge criteria for patients and families and notify RN Case Managers of newly‑identified resources or changes in previously‑identified resources.
• Educate patient/family and physician regarding post‑acute options and address issues of choice.
• Patient and Family Support in Legally Complex Cases
• Provide intervention in child abuse/neglect, domestic violence, guardianship (temporary/ permanent), foster care, adoption, mental health placement, advance directives, adult/elderly abuse, child protection, and sexual assault.
• Ensure safe care to patients adhering to policies, procedures, and standards within budgetary specifications including time management, supply management, productivity, and accuracy of practice.
• Promote individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, and supporting department‑based goals that contribute to the success of the organization.
• Actively participate in care conferences and multidisciplinary rounds.
• Advocate for patient and family empowerment and independence to make autonomous healthcare decisions and to access needed services within the healthcare system.
• Actively participate in clinical performance improvement activities as assigned.
• May provide supervision of Social Worker interns, MSW’s with less than 4,000 hours of hospital…