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Summary Description The Social Worker is responsible to facilitate care along a continuum
through effective resource coordination to help patients achieve optimal
health, access to care and appropriate utilization of resources, balanced
with the patient's resources and right to self-determination. The
individual in this position has overall responsibility for to assess the
patient for transition needs including identifying and assessing patients
at risk for readmission. Conducts complex psycho-social assessment and
intervention to promote timely throughput, safe discharge and prevent
avoidable readmissions. This position integrates national standards for
case management scope of services including:
Transition Management promoting appropriate length of stay, readmissionprevention and patient satisfaction
Care Coordination by demonstrating throughput efficiency while assuringcare is the right sequence and at appropriate level of care
Compliance with state and federal regulatory requirements, TJCaccreditation standards and Tenet policy
Education provided to physicians, patients, families and caregivers
This individual's responsibility will include the following activities: a)
complex psycho-social transition planning assessment and reassessment and
intervention, b) assistance with adoptions, abuse and neglect cases,
including assessment, intervention and referral as appropriate to local,
state and /or federal agencies, c) care coordination, d) implementation or
oversight of implementation of the transition plan, e) leading and/or
facilitating multi-disciplinary patient care conferences including Complex
Case Review, f) making appropriate referrals to other departments, g )
communicating with patients and families about the plan of care, h)
collaborating with physicians, office staff and ancillary departments, i)
assuring patient education is completed to support post-acute needs , j)
timely complete and concise documentation in Case Management system, k )
maintenance of accurate patient demographic and insurance information, l)
and other duties as assigned.POSITION SPECIFIC RESPONSIBILITIES: Transition Management· Completes comprehensive assessment within 24 hours of patient
admission to identify and document the anticipated transition plan for
patients· Integrates key elements of patient assessment, patient choice and
available resources to develop and implement a successful transition plan· Completes Complex/Psycho-social assessment and plan for patients
identified as high risk for readmission.· Provides psycho-social assessment and intervention for patients
identified with identified needs including behavioral health, lack of
support systems, financial barriers, end of life, and/or medication
adherence.· May delegate the implementation of the transition plan to LVN/LPN or
Assistant staff. And follows up to ensure the transition plan is completed
timely and accurately· Ensures all elements of the transition plan are implemented and
communicated to the healthcare team, patient/family and post-acute
providers· Provides information to patients to make informed choices when
community services per Tenet policy· Completes Final Discharge Disposition Form Assessment for Medicare
patients per Tenet policy· Completes timely, complete and accurate documentation in the Tenet
Case Management system to communicating information to the care team and
provide documents needed in the patient record(40% daily, essential)Care Coordination· Screens patients for factors that may affect the progression of care
and intervenes as needed to promote timely and appropriate throughput· Conducts assessments and stratifies patients at risk for readmission
or in need of Case Management services· Assists with adoption/abuse/neglect cases and reporting of
appropriate cases to local, state and/or federal agencies· Ensures the plan of care is consistent with patient choice and
available resources· Ensures patient needs are communicated and that the healthcare team
is mutually accountable to achieve the patient plan of care·Effectively collaborates with physicians, nurses, ancillary staff, payors,
patients and families to achieve optimal outcomes(40% daily, essential).Education· Ensures and provides education to patients, physicians and the
healthcare team relevant to the safe and timely patient transition· Provides patient and healthcare team education regarding resources
and benefits available to the patient along with the economic impact of
care options· Ensures that education has been provided to the
patient/family/caregiver by the healthcare team prior to discharge(10% daily, essential).Compliance· Ensures compliance with federal, state, and local regulations and
accreditation requirements impacting case management scope of services· Adheres to department structure and staffing, policies and
procedures to comply with the CMS Conditions of Participation and Tenet
policies· Operates within the Social Work scope of practice as defined by
state licensing regulations(10% daily, essential)Minimum Qualifications
Master's degree in Social Work from a college or university social work
program approved by the Michigan Board of Social Work and accredited by the
Council on Social Work Education.
Current license as a Licensed Master's Social Worker in the State of
Michigan, or current limited license to engage in the practice of social
work at the Master's level in the State of Michigan, with full licensure
within 3 years from date of hire .
Two years of acute hospital experience preferred.
Must complete and demonstrate competency in using the Tenet Case
Management documentation system within 30 days of hire.
Attendance at hospital and department orientation is required.
Department orientation includes review and instruction regarding Tenet Case
Management and Compliance policies, Transition Management, and other topics
specific to case management.
Accredited Case Manager (ACM) preferred.
Skills Required
Analytical ability, critical thinking and problem solving skills to
identify opportunities for improvement and problem resolution.
Interpersonal skills necessary to work productively with patients,
families and all levels of hospital personnel.
Verbal and written communication skills to communicate effectively with
diverse populations including physicians, employees, patients and their
families.
Ability to cope with stressful situations or encounters, manage multiple
and sometimes conflicting priorities, and to work regularly with difficult
medical/emotional/psycho-social problems.
Teaching abilities to conduct educational programs for staff, patients,
families and community.
Organizational skills and the ability to lead and coordinate activities
of a diverse group of people in a fast paced environment.
Comprehensive knowledge base and physical ability to systematically
assess patients and families to identify psychosocial health status and
needs.
Computer literacy to utilize case management systems.Job: Therapy and RehabilitationOrganization: DMC Sinai-Grace HospitalTitle: Clinical Social Worker Emergency Part Time Midnight Shift Sinai Grace HospitalLocation: MI-DetroitRequisition ID: 2005028862
