Licensed Clinical Social Worker

Using evidenced based guidelines and best practice as a

foundation, the Licensed Clinical Social Worker is responsible for performing

bio-psycho-social assessments, care coordination and clinical interventions,

program development & discharge planning. Effectively intervenes with

medically and psychosocially complex patients, while demonstrating the ability

to understand complex dynamics related to the clinical situation. Medical

Social Worker ensures that the patient and family experience adhere to Cottage

Health Patient First Philosophy and is consistent with the Mission and Vision

of our health care organization.

This is not an exhaustive statement of duties, responsibilities, or requirements. Employees will be required to perform any job, with related instruction given by their supervisor, subject to reasonable accommodation.

* Psychosocial Assessment:
Assess the patient?s social situation, dynamics and capacity to cope with the illness, treatment and hospitalization. Coordinate with multidisciplinary team members, including outside agencies or systems and act as liaison between medical team and the patient and family system. Identify and use differential diagnoses as appropriate for the psychological, emotional or social barriers that interfere with medical treatment, positive outcomes, or discharge plan in various adult and pediatric settings.

Clarify and address conflicts that might arise between medical team and the patient and/or family system, may include identifying legal guardian and family spokesperson or agent for Advanced Directive compliance. Assist with establishing Advanced Directive and Power of Attorney. Act as advocate for patients, families and Cottage Health. Provide medical crisis counseling and emotional support to patients, families and staff around psychosocial stressors, adjustment to illness, end-of-life, grief, and bereavement issues.

Consult and conduct assessment and make appropriate referrals on suspected child, dependent adult or elder abuse, domestic violence, substance abuse issues and mental illness cases. Act as liaison between patient/family and schools, work sites. Discuss cases as appropriate with relevant stakeholders (such as patient, physicians, other providers and payers) to best align social work case management plan, level of care and funding resources.

Provides a high level of clinical expertise, critical thinking and problem solving skills to situations in order to achieve desired outcomes. Maintain timely and accurate records of all activities relating to the assessment process, documenting activities as appropriate in the medical record. (30%)

* Discharge Planning:
On admission, participates in the coordination and development of a discharge plan. In conjunction with the healthcare team, patient and family stakeholders identifies likely post-discharge needs. Provides appropriate information, education and choice, making referrals as appropriate to implement the discharge plan (i.e. charity applications, Family Assistance Fund, community resources, home healthcare, institutional placements, financial assistance, DME equipment needs and/or alternative/specialized care settings).

Resource linkage for uninsured and/or underinsured patients, displaced families, immigrants and refugees who need medication and aftercare placements in shelters/transitional housing, sober living, SNF, substance abuse residential programs, etc. Use multidisciplinary collaboration, hospital programs and resources, community resources, home care services, institutional placements, financial assistance and mental health counseling to plan and coordinate patient apos;s discharge as needed. Facilitates the transfer of patients to other care facilities as appropriate.

Intervene with behaviorally challenged patients and/or patients unwilling to leave hospital to facilitate a safe/timely discharge plan. Maintain timely and accurate records of all activities relating to discharge planning, documenting activities as appropriate in the medical record. (30%)

* Resource Coordination:
Ascertain healthcare benefits utilizing both internal and external resources as appropriate to coordinate…