| Performs accurate and comprehensive assessments. |
| Obtains physician orders for certification and recertification of home medical social work services. |
| Ensures that changes in patients' clinical status are communicated to other healthcare team members and Agency office staff verbally and in writing in a timely manner. |
| Ensures that physician orders are communicated to other healthcare team members and Agency staff in a timely, accurate, and thorough manner. |
| Coordinates care planning and delivery with the physician, patient and family/caregivers, other healthcare team members and Agency staff to facilitate optimal patient outcomes. |
| Educates patients, their families/caregivers and other staff as appropriate, in appropriate medical social work modalities and interventions. |
| Delivers medical social work modalities and interventions appropriate to the patient's clinical status and needs and in accordance with the standard of care for patient's age. |
| Provides, modifies or discontinues medical social work modalities and interventions based upon an ongoing assessment/reassessment of the patient's clinical status and in accordance with physician orders. |
| Synthesizes assessment data and analyzes data to make clinical judgments regarding patient management. |
| Provides medical social work modalities in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors. |
| Identifies risk of injuries or threats to life and health in the patient's environment, i.e., environmental/safety/mobility risks and implements appropriate interventions to reduce those risks. |
| Addresses and supports cultural practices providing such practices do not harm the patient or others, and do not interfere with the planned course of medical social work. |
| Performs transfer and discharge planning functions in accordance with Agency policy and applicable laws, regulations and standards. |
| Participates in the organization's information management program. |
| Complies with the Agency's policies. |
| Adheres to all applicable laws, regulations and standards. |
| Completes and submits necessary documentation in accordance with Agency policy and applicable regulations. |
| Submits verification of completed visits in accordance with Agency policy. |
| Participates in interdisciplinary team conferences in accordance with Agency policy. |
| Maintains current knowledge of community resources. Identifies and accesses appropriate external and internal resources to meet patient and/or family needs and to facilitate optimal patient outcomes while home care services are being provided, and for transfer and discharge processes. |
| Adheres to dress code. |
| Completes annual educational requirements. |
| Maintains regulatory requirements. |
| Wears identification while on duty. |
| Maintains confidentiality at all times. |
| Attends department staff meetings as required within the department. |
| Reports to work on time and as scheduled; completes work in designated time. |
| Represents the organization in a positive and professional manner. |
| Actively participates in performance improvement and continuous quality improvement (CQI) activities. |
| Coordinates efforts in meeting regulatory compliance, federal, state and local regulations and standards |
| Communicates and complies with the Benefis Health System Mission, Vision and Values as well as the focus statement of the department. |
| Complies with Benefis Health System Organization Policies and Procedures. |
| Complies with Health and Safety Standards and Guidelines. |
