Social Worker MSW II - Research Grants Legacy

Summary /p

This position is responsible for assisting in meeting the patient’s needs throughout the continuum of care. Guides patients, families, physicians, and to the appropriate community and adjunct resources that foster quality of life. Interviews patients and families/support systems to obtain an age-specific psychosocial assessment. Assists patients and families in adjustments to illness, disabilities, and resolving difficulties which interfere with the care management process.

Provides psychosocial assessments and develops an interdisciplinary plan of care with the patient and stakeholders to best meet the needs of patients and families. Implements/assist with discharge planning services related to the complex patient.

Summary pThis position is responsible for assisting in meeting the patient’s needs throughout the continuum of care. Guides patients, families, physicians, and to the appropriate community and adjunct resources that foster quality of life.

Interviews patients and families/support systems to obtain an age-specific psychosocial assessment. Assists patients and families in adjustments to illness, disabilities, and resolving difficulties which interfere with the care management process.

Provides psychosocial assessments and develops an interdisciplinary plan of care with the patient and stakeholders to best meet the needs of patients and families. Implements/assist with discharge planning services related to the complex patient.

Responsibilities ul liDevelops plan of care in collaboration with the RN case manager, physician, and patient to secure the best discharge plan available to the patient. liAssessment and planning for the social requirements of patient and family of patient in long term care planning. liMaintains liaison with agency sources such as "Make A Wish"/"Ronald McDonald House". liDiscuss patient’s length of stay (LOS) of 4 days or greater, and outliers at weekly interdisciplinary/outlier meetings.
liAttends and actively participates in interdisciplinary patient care rounds on a weekly basis and works with the health care team to collaboratively formulate appropriate and realistic discharge plans. liAssesses and continually reassesses the psychosocial/concrete needs of family members /support systems that may interfere with optimizing the patient’s care management (Medicaid, housing, food stamps, etc). liDemonstrates awareness of the importance of addressing patient’s quality of life by maintaining current and up to date information of community resources and refers patients to those community resources which will enhance patient’s life to include initiating Medicaid transportation documents and meal ticket distribution when necessary.

Initiates referrals to pharmaceutical companies to assist patient and families with high-cost medications. liProvides resource/referral for counseling services and other recognized psychosocial therapies, child abuse referrals, adult protective service referrals, guardianship petitions and psychiatric petitions. Initiates referrals and appears in court as subpoenaed liDemonstrates competence to perform assigned patient care responsibilities in a manner that meets the age-specific and developmental needs of the patients served by the department.
liProvides referral to Spiritual Care and can assist in crisis intervention to patients and their family members involved in emergency trauma, deaths, loss of home, family violence, etc. liAssess high-risk patients who exhibit behaviors that are maladaptive to the adjustment of the illness and /or disability. liChange Management:
Acts as a catalyst for change in the organization; responds to change with flexibility and adaptability to overcome organizational resistance and inertia; demonstrates the ability to focus and energize associates to work together for change; gains maximum support from others for new initiatives. liShaping the Organization:
Devises systems and processes which improve the overall functioning of the organization; ensures that the organization’s systems, processes and people are integrated to achieve the mission in the most efficient and effective manner. liManagi…