Summary: Provides and/or oversees the provision of appropriate and timely resources, interventions, and services for selected patients in the hospital. Collaborates with the interdisciplinary team of healthcare professionals involved in the plan of care for high-risk patients including, but not limited to, hospital-based Case Management and clinical staff, the patient's primary provider, High Risk RN Care Coordinator, practice team members and community partners. Ensures that plans are focused and effective which helps patients to connect with and utilize a full range of medical, community and other services available. Essential Duties and Responsibilities Supports and promotes the mission and values of Covenant Health Ministry. Provides assessment of patient Social Determinants of Health which may include: o Living situation – environment, safety, abuse & neglect o Risk to self or others o Substance misuse o Financial resources o Behavioral health history o Barriers to care o Cultural issues o Coping style o Life transition o Understanding of illness/disease process(es) o Primary Care Provider o Advance Directives – DPOA, Guardianship, etc. Provides psychosocial evaluation/assessment of patient family/caregivers Assesses learning and coping styles, cultural issues, family resources and readiness to participate Makes recommendations for direct service and/or referral for a wide range of community resources, based on assessment of patient/family needs Acts as a patient advocate to ensure patient/family receives access to services. Readmission review and interventions placed to prevent further readmissions Provides direct intervention to patients/families based upon the assessment, need and patient consent Provides financial information for patients/families Facilitates Medicaid applications and/or other financial assistance from the community as needed by patient/family Acts upon referrals for Social Work within one business day Works collaboratively and effectively with the interdisciplinary team and community partners Assists with provision of seamless transition across the continuum of care Facilitates support groups for the community according to identified needs Maintains effective working relationships with community partners Facilitates Advance Directives as requested Conducts patient/family meetings Assists the patient/family to understand and accept medical recommendations and supports patient/family with decisions Facilitates team conferences, discharge planning and family conferences Meets patients at practices, hospital, community and/or in home as needed Documentation is timely, precise, and relevant Demonstrates ability to organize workload and set appropriate priorities based on patient’s medical needs, preference, availability of service, and patient/family compliance. Maintains current knowledge of organization’s policies and procedures. Maintains clinical competence in relation to social work practice in Hospital. Maintains/enhances professional development and personal growth required to perform as social worker and to fulfill organizational requirements. Participates in peer review with team members May provide clinical supervision to undergraduate and/or graduate level social work students in field work placement with St. Joseph Hospital. Acts as a patient advocate to ensure patient/family receives access to services. Develops and implements process improvement activities on assigned units. Identifies opportunities for improvement in hospital-wide systems for the delivery of social services. Identifies high risk patients & families and makes referrals to Quality and Risk Management. Stays current with DNV & CMS regulations as well as State regulations that pertain to Social Services Assists in writing policies, memos, and patient/family education material as assigned. Assists in the planning and development of programs and special projects. Serves on assigned hospital committees. Performs various assignments as requested by the Director of Care Coordination. Other duties as consistent with this role. Job Requirements Job Knowledge and Skills Experience and comfort working with adult patients >18 who have complex medical and/or psychiatric problems. Ability to work with families of diverse patient populations Ability to assist patients/families understand and access resources Strong assessment and organizational skills Ability to advocate/negotiate for patients through systems Good organizational skills Demonstrated ability to communicate effectively verbally and in writing Strong interpersonal skills enabling effective team collaboration Maintains confidentiality Ability to work remotely as needed Education and Experience MSW required LICSW preferred Knowledge of end-of-life issues preferred Knowledge of community agencies and resources preferred Minimum of two years’ experience in a health care setting preferred An equivalent combination of education and experience which provides proficiency in the areas of responsibility listed above may be substituted for the above education and experience requirements. Working Conditions/Physical Demands Must possess the physical and mental abilities to perform the tasks normally associated with this position that involves a combination of sitting, standing, walking, bending, stooping, and reaching. Lifting/carrying frequently up to 35 pounds, and occasionally up to 50 pounds. Some stress related to high level of responsibility for quality care. Covenant Health Mission Statement We are a Catholic health ministry, providing healing and care for the whole person, in service to all in our communities. Our Core Values: Compassion We show respect, caring and sensitivity towards all, honoring the dignity of each person, especially the poor, vulnerable and suffering. Integrity We promote justice and ethical behavior, and responsibly steward our human, financial and environmental resources. Collaboration We work in partnership, dialogue and shared purpose to create healthy communities. Excellence We deliver all services with the highest level of quality, while seeking creative innovation.
