This position is responsible for assisting in meeting the patient's needs throughout the continuum of care. Guides patients, families, physicians, and to the appropriate community and adjunct resources that foster quality of life. Interviews patients and families/support systems to obtain an age-specific psychosocial assessment. Assists patients and families in adjustments to illness, disabilities, and resolving difficulties which interfere with the care management process. Provides psychosocial assessments and develops an interdisciplinary plan of care with the patient and stakeholders to best meet the needs of patients and families. Implements/assist with discharge planning services related to the complex patient.
Psychosocial Assessment and Interventions
Uses preliminary risk screening to assess patient/family risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness, and ability to cope.
Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability; access and mobilize family/community resources to meet identified needs.
Provide intervention in cases involving child abuse/neglect, domestic violence, elderly abuse, institutional abuse, and sexual assault.
Serves as resource and provide support related to treatment decisions and end of life issues.
Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the health care system.
Provides intervention and support in domestic violence, guardianship, foster care, adoptions, surrogacy, mental health placement, and advance directives.
Demonstrates competence to perform patient care responsibilities in a manner that meets the age-specific and developmental needs of the patients served by the department
Complex Discharge Planning
Participated in discharge planning activities for complex patients in order to ensure timely discharge and to provide appropriat linkage with post-discharge care providers
Deals with families exhibiting complex family dynamics that impact directly on patient care and discharge.
Collaborates with RN Case Managers, physicians and the patient regarding the discharge planning status
Develops plan of care in collaboration with the RN case manager, physician, and patient to secure the best discharge plan available to the patient
Assessment and planning for the social requirements of patient and family of patient in long term care planning
Validates discharge criteria for patients and families
Educates patient/family and physician regarding post-acute care options based upon criteria and addresses issues of choice.
Closely monitor patient length of stay in regard to the geometric mean length of stay and communicate/collaborate with appropriate interdisciplinary team members to remove barriers and expedite discharge.
Attends and actively participates in interdisciplinary patient care rounds and works with the treatment team to formulate appropriate and realistic discharge plans.
Initiate referrals to pharmaceutical companies to assist patients and families with high cost medications.
Initiates referral to appropriate post-actue care providers, other health care providers, and community service agencies to assist patients and families with identifying resources to enhance and improve both the patient's state of health and quality of life.
Provides brief counseling and intervention
Serves as preceptor, mentor, trainer and/or resource to new or less experienced staff.
Ensures safe care to patients adhering to policies, procedures, and standards, within budgetary specifications, including time management, supply management, productivity and accuracy of practice.
Promotes individual professional growth and development by meeting requirements for mandatory and continuing education, skills competency, supports department based goals which contribute to the success of the organization.
Change Management: Acts as a catalyst for change in the organization; responds to change with flexibility and adaptability to overcome organizational resistance and inertia; demonstrates the ability to focus and energize associates to work together for change; gains maximum support form others for new initiatives.
Shaping the Organization: Devises systems and processes which improve the overall functioning of the organization; ensures that the organization's systems, processes and people are integrated to achieve the mission in the most efficient and effective manner.
Managing Process: Translates strategies into action steps; clearly assigns responsibility for decisions and tasks; sets clear objectives.
Master's Degree in Social Work from accredited institution
Strong interview, assessment, organizational and problem-solving skills
Excellent interpersonal communication and negotiation skills
Ability to work with people of all social, economic and cultural backgrounds
Ability to analyze, develop and manage change
Ability to work independently and to develop relationships with physicians, families, patients, interdisciplinary team and community agencies
Demonstrates ability to connect patients and families with necessary services
Maintain working knowledge of resources and services available in the community including options for those with limited or non-existent funding options
Three to Five years hospital social work experience or applicable social service experience preferred or proven success as Social Worker MSW II or Social Worker LCSW II
LCSW License in state of employment Case Management Certification preferred
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.