Works collaboratively with the care management team for coordinated patient care delivery across the continuum. Provides psychosocial clinical assessment, intervention, evaluation, consultation and education to patients/families as part of comprehensive care management services. Identifies high risk patients from a psychosocial/ financial perspective and provides information, support, counseling, care management, and referrals to appropriate resources. Serves as a liaison for complex transitions/discharges between the hospital and community agencies for the exchange of clinical and referral information. Contributes to training of social work professionals as part of the education program at Loyola University Health System.
Assesses patient's mental and social functioning by providing a psychosocial screen/ history, assessment, resource information, counseling and a discharge plan within 24 hours of referral. Performs high risk screenings to assist with management of self-referrals. Responds to patient and family requests on same day. Develops and implements appropriate treatment plans and interventions. Utilizes crisis interventions to mobilize resources to ensure appropriate response. Makes referrals to appropriate community resources. Refers to appropriate resources regarding insurance issues. Educates patient and family regarding healthcare delivery systems, including resources and limitations.
Provides counseling/interventions to patients and families in relation to social, psychological, financial, and family situations which will allow timely discharge or transition facilitation. Meets with identified patients and families to provide psychosocial support. Obtains, interprets, and communicates necessary information (both verbally and documented into medical record) regarding patients and families, including social history, to staff and physicians in a timely manner. This includes providing counseling and appropriate interventions and referrals for all patients admitted secondary to criminal and/or sexual assault, adult/child abuse and neglect, domestic violence, acute psychiatric conditions, and substance abuse. Attends unit-based and/or service line multidisciplinary rounds. Facilitates patient and/or family decision-making regarding initiation and/or discontinuation of treatment, life support, etc. and uses internal resources such as chaplains, ethics committee referrals when needed. Identifies, organizes and leads family care conferences as a mechanism to progress care planning and transitions.
Facilitates and coordinates details of placement and actual discharge of complex discharges to appropriate agencies. Discusses nursing, psychosocial needs and medical information with facilities. Provides and updates referrals to facilities through online/software discharge planning tools or defined department procedures or processes. Reviews and completes/approves all appropriate information accompanying patient to a facility. Acts as a liaison between hospital and facilities for complex discharges. Coordinates time and mode of transportation to facilities for complex discharges.
Participates in departmental and hospital performance improvement, lean management, and quality programs. Provides complete documentation of initial assessments, progress notes and review of all referrals for accuracy and content prior to discharge. Initiates and/or monitors completeness, accuracy and timeliness of all documentation, including appropriate federal, state and local forms. Attends Social Work/ Case Management staff meetings. Reports potential risk or quality management issues to department manager or director. Enters data as requested to support quality improvement initiatives. Documents in EPIC all pertinent patient information by the close of business each day. Consults with attending physician/resident/ fellow/APN or physician advisor to resolve barriers through appropriate administrative and medical channels. Complies with all applicable state and federal regulations and recommendations of outside regulatory bodies, including insurance companies as it pertains to discharge planning.
Maintain current knowledge base of clinical social work and utilization standards and promotes quality/research initiatives. Adheres to Patient Bill of Rights, Social Workers' Code of Ethics and professional responsibilities outlined by NASW. Seeks opportunities to meet learning needs through seminars and literature, including mandatory education requirements. Demonstrates capability to adapt and change work processes and role responsibilities or activities to improve service delivery. Establish effective networks with colleagues inside and outside Loyola University Health System. May mentor Social Work students as a Field Instructor in conjunction with the Social Work Student Coordinator and the specific university liaison. Participates in pertinent professional education, including LCSW or certification, if applicable.
III. Position Requirements :
Required: Masters Degree
Specify Degree(s): Masters of Social Work
Residency: Internship in Inpatient Hospital Setting Preferred
Preferred: 1-2 years of previous job-related experience
Details: Expected to have CMA certification within 3 years of hire.
Managerial Experience: N/A
Licensed Social Worker
Licensed Clinical Social Worker
Other: Expected to have CMA certification within 3 years of hire.
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