Medical Social Worker-Hospice-GIP at Carilion Clinic Roanoke, VA

Medical Social Worker-Hospice-GIP job at Carilion Clinic. Roanoke, VA.

This position is with our Roanoke Hospice team, working mainly out of Carilion Roanoke Memorial Hospital with our General Inpatient patients. Some travel may be required.

Is an integral part of the care team, contributing professional expertise to support the holistic health of the patient and support for family and/or other caregivers. In collaboration with the health care team the medical social worker assists patients and families with personal and environmental difficulties which predispose illness or interfere with obtaining maximum benefits from medical care. Provide patient and families with the psychosocial support needed to cope with disease and life limiting illness.

Services include advising family and caregivers, providing education and support, and making referrals for other services as needed or requested.

• Provide psychosocial assessments of patients and families to identify emotional, social and environmental strengths and problems related to their preventative health management, diagnosis, illness, treatment, and/or life situation. Utilize assessment and social work experience to plan and coordinate patient care.
• Formulate, develop, and implement a comprehensive treatment plan utilizing appropriate social work interventions. Coordinate the plan with the care team and make recommendations for further treatment for the patient to achieve his/her optimal level of healthy lifestyle, behaviors and functioning. Evaluate the process at appropriate intervals and modify or change the plan as necessary. Monitors utilization of healthcare resources such as ED, urgent care, admissions or frequent office visits.
  
  Collaborates with team to address unnecessary utilization and plan for appropriate support to modify process behaviors. Monitor, evaluate, and record client progress according to measurable goals described in treatment and care plan.
• Arranges, secures, and coordinates assistance with unmet patient/family needs, to include social service, financial, and insurance applications and follow up, medications, DME, and transportation to/from clinic appointments. Plan of care promotes compliance as well as considers appropriate utilization of resources. Advocates on behalf of the patient. Advocates for patients to assist in crises situations.
• Participates in care transitions post hospital and/or ED discharge follow up to assess psychosocial and support needs and reinforces patient self-management expectations and goals.
• Collaborates with other professionals to evaluate patients’ medical or physical condition and to assess patient needs.
• Collaborates with community agencies and resources to develop comprehensive knowledge base of available resources for patients and families.
• Refer patient or family to community resources to provide access to services such as financial assistance, legal aid, or housing.
• Participates in care team pre- and post visit case reviews and related meetings. Collaborates with the health care team and/or care coordinator verbally or via chart entries related to the patient’s progress toward reaching expected outcomes or about barriers to the plan.
• Meets documentation standards for quality, timeliness and confidentiality of medical records in accordance with organizational and departmental defined policies and procedures.

Education: Bachelor's degree with major studies in social work, sociology or psychology from a four-year college or university accredited by the Council on Social Work Education or 8 additional years of experience required.

Experience: Social work experience in healthcare setting preferred.
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