Employment Type:Full time
Shift:Day Shift
Description: To provide professional discharge planning services through assessments, and coordination of
post-hospital care needs to patients and their families. Provides resources and choices to families
to effectively link them to the needed level of emotional, medical and spiritual care.
This role will receive referrals for individuals from at-risk populations from interdisciplinary
team members (including physicians, Care Managers, staff nurses and other members of the
care team). Participates as an active member of multi-disciplinary team.
II. Position Responsibilities: No. Percent of Time Essential Duty Job Duties 1
55%
Yes
Complex Discharge Planning based on assessment of patient and family
needs, preferences and available resources in order to ensure a timely
discharge and to provide appropriate linkage with post-discharge care
providers( i.e. New/Resumptions SNF, LTAC, Rehab, Dialysis, Hospice,
DME and Home Health etc.)
1.Develops discharge plan in direct consultation with patient, family, physician, and
health care team. Deals with families exhibiting complex family dynamics that
impact directly on patient care and discharge.
2.Manages complex cases/situations and intervenes with and advocates for patients
and families as plan of care and discharge plan are developed.
3.Educates patients and families regarding appropriate resources, access to services
and third party requirements, and makes appropriate and timely referrals to
address post-acute discharge needs.
4.Provides consultation to Case Managers when coordination with significant or
intensive community resources is necessary to achieve desired treatment outcomes
5.Uses knowledge of insurance benefits and coverage guidelines to maximize
appropriate utilization of resources.
6. Maintains effective communication and working relationships with members of
the interdisciplinary team.
7.Attends care conferences/unit huddles or other care planning meetings as per
department policy.
8.Partners with external agencies and facilities to provide continuity of care for
patients and families.
9.Documents all interventions and discharge plans to provide the health care team
with accurate and up-to-date information regarding development/progress of the
discharge plan and psychosocial interventions with responses.
B. Completion of an assessment/history on all identified patients within
appropriate time frames.
1.Interviews patient and significant others to assess patient's psychosocial situation.
2.Identifies patient and family preferences, needs and strengths, to foster for the
patient and family empowerment and independence to make autonomous health
care decisions and access needed services within the health care system.
35%
C. Psychosocial Assessment and Interventions on the basis of preliminary risk
screening, assesses patients and family's psychosocial risk factors through
evaluation of prior functioning levels, appropriateness and adequacy of
support systems, reaction to illness and ability to cope. Supportive counseling
and clinical Social Work intervention for patients and families in acute
emotional distress.
1.Counsels patients and families regarding issues of loss, disability, separation,
financial impact, and traumatic life style changes. Coaches families in developing
coping mechanisms to support adaptation to changes.
2.Counsels and assists patients and families regarding Advanced Directives, end of
life issues, and ethical issues that may arise.
3.Interacts with appropriate agencies on issues of suspected abuse and neglect,
domestic violence, guardianship, and other social/legal matters. Utilizes crisis intervention techniques when indicated.
5.Provides referrals to community-based support resources as appropriate.
6. Manages the progression of patients stay with the goal of optimizing the LOS and
ensuring appropriateness of assigned Level of Care.
2.Manages the patients care across the continuum to decrease unnecessary
readmissions.
3.Manages and coordinates patient care within an ACO environment to help
facilitate patient outcomes through in network care coordination.
D Engages in Performance Improvement and patient safety initiatives.
1.Identifies and communicates quality, risk, and patient safety issues to Care
Management or other appropriate leadership.
2.Accepts responsibility by participating in staff, department, or Organizational
process improvement and safety initiatives.
10%
E. Professional Development: Maintenance of professional standards and responsibilities for his/her own professional practice according to accreditation, hospital, system, state and NASW Standards and Code of Ethics.
1.Completes all required continuing education to maintain licensure and increase
knowledge within area of practice specialty.
2.Completes and utilizes all annual safety and competency training.
3.Maintains up-to-date knowledge of community resources, legislation, and
regulations impacting health care delivery and educating patients and families on
these issues as appropriate
Freedom of Action: Supervisory Responsibility: - Staff: N/A - position does not supervise staff
- Functional: N/A - no functional supervisory responsibilities
Safety Accountabilities: - Loyola is committed to providing care that is safe. It is expected that all Loyola employees will perform their job function in a professional and competent manner that constantly seeks to reduce the risk of harm to patients, families and co-workers.
Quality Improvement Accountabilities: - Loyola is committed to the continuous improvement of the services it provides to its patients and their families. All Loyola employees are expected to participate in quality improvement activities.
Service Excellence Accountabilities:- Responsible for consistently demonstrating our values of Care, Concern, Respect and Cooperation through teamwork and effective communication in an effort to prevent and solve problems and to achieve quality outcomes, patient safety, customer satisfaction and a safe environment.
- Responsible for developing and maintaining an environment of service excellence as outlined in the Service Excellence standards.
III. Position Requirements:
Minimum Education:- Required: Masters Degree of Social Work from an accredited school
- Preferred: Masters of Social Work with Clinical Licensure
- Specify Degree(s): N/A
- Residency: N/A
Minimum Experience: - Required: 1-2 years of previous job-related experience
- Preferred: N/A
Managerial Experience: N/A
Licensure/Certifications: - Required: LSW,
- Preferred: LSW, LCSW or ACM
- Other: N/A
Computer Skills: Required:- Microsoft Excel
- Microsoft Outlook
- Microsoft Power Point
- Microsoft Word
Typing Words Per Minute: N/A
Required Skills: - Ability to communicate verbally
- Effective time management, organization and documentation skills necessary
- Ability to deal calmly and courteously with people
- Ability to manage crisis situations
- Resiliency and flexibility to effectively work within a constantly changing health-care environment
- Fast paced work environment with
- Ability to maintain accuracy and consistency
- Ability to maintain office files and follow standard office procedures
- Ability to work as an effective team member
- Other: N/A
Personal Relationships: - Routine job with interpersonal contact
Internal Contacts: - Within Department
- Physicians
External Contacts: - Other healthcare agencies
- Post-acute nursing facilities/resources
Working Conditions: - Normal light, heat, air and space in work environment
- Work takes place on hospital unit or clinical setting
Physical Demands: - Occasionally:
- Frequently:
- Standing
- Sitting
- Reaching with Arms
- Finger/Hand Dexterity
- Talking
- Hearing
- Seeing
Our Commitment to Diversity and Inclusion Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color . click apply for full job details