Provides social work intervention, and proactive discharge planning support to patients and their families. Provides psycho-social assessment and appropriate input into the plan of care. Collaborates with the interdisciplinary team to ensure timely interventions to support the patient transition to the next level of care at the point they are medically ready to transition. Works with post-acute care providers to ensure coordinated and timely patient transitions.
Coordinates and optimizes throughput activities to optimize high risk patient outcomes including:
- Completes thorough chart review upon referral and throughout patient's stay.
- Attends Bed Huddles and Care Conferences daily to promote throughput activities.
- Provides information to Care Coordinator and Charge Nurse related to pending and confirmed discharges to leadership and the Logistic Center to assist in Throughput throughout patient's hospitalization.
- Participates in ongoing communication with physician and interdisciplinary team to develop a collaborative relationship aimed at improving clinical treatment goals and appropriate and timely discharge for the patient.
- Proactively educates patients upon referral about advance directives, options for post-acute services and community resources available to them at discharge.
- Completes proactive initial and ongoing psychosocial assessments that holistically assess the patient for potential complex post- acute needs. (i.e. assesses for abuse/neglect/substance abuse/mental health/homeless/end of life/ lack of payor/ facility placement issues.)
- Provides support to patients with issues related to adjustment to illness and assists in securing support for them post hospitalization.
- Identifies hospital and community based resources which will meet patient/family needs and provides referrals and advocacy in obtaining services.
- Maintains active interaction with the patient/family throughout the treatment/discharge planning process in efforts to keep them apprised of discharge planning activities.
- Proactively makes appropriate referrals to internal and post-acute service providers to ensure continuity of care during and post hospitalization.
- Provide expertise to the team in developing treatment and discharge planning strategies for frequently admitted patients.
- Assists in the procurement of services and serves as an advocate on behalf of patient/family for scarce resources.
- Maintains high team standards by addressing coordination problems within the functioning of the healthcare team.
- Identifies and escalates any issues that relate to LOS/Throughput/Readmission management.
- Provides to patients, families, and hospital staff education regarding post- acute services (LTACH, acute rehabilitation, nursing facility, hospice, etc.) Opportunities for conducting education may include patient families at bedside, one-on-one staff education, and unit department meetings.
Maintains skills and knowledge as appropriate to the medical social work role. Participates in continuing education to fulfill licensure requirements.
Documents throughput/ discharge planning activities according to departmental policies:
- Completes data collection via designated software for all patients.
- Identifies and documents all social work intervention and discharge planning activities in appropriate software.
- Communicates only appropriate necessary information on chart applicable to the referral source in accordance with HIPPA guidelines
Education, Credentials, Licenses:
Graduate of an accredited masters' school of social work. Licensed as an SW to practice social work in the state where work is being performed. Meets contact hour requirements for licensure, including all state required courses.
- Knowledge of psychosocial issues re: health related problems and post-acute care needs.
- Excellent communication skills and the ability to coordinate care well with an interdisciplinary team.