Work Hours/Shift: Monday - Friday, 8:30am - 5:00pm with rotating weekends and holidays as needed
You Will Be Responsible For:
â— Psychosocial Assessment and Interventions
â— Receives referrals for psychosocial complex needs from the health care team.
â— Provides assessment and reporting interventions in child abuse/neglect, domestic violence, adult/elderly abuse, child protection, sexual assault, and human trafficking as appropriate.
â— Provides consult services for patients who may possibly lack decision making capacity. Follows the guardianship (temporary/ permanent) policies and procedures and coordinates with Care Management leadership throughout the process.
â— Provides consult services for foster care and adoptions.
â— Assists the health care team in the patient assessments and placements for mental health services.
â— Facilitates full team discussion including patient and family when ethical dilemmas arise.
â— Promotes the understanding and use of advanced directives and ensures patient preference and care goals are followed
â— Completes Initial Evaluation for transition of care needs on all identified patients within one calendar day of admission and documents according to policies and procedures. Interviews patient and involved care givers (as permitted by the patient) as well as a review of the current and past inpatient and outpatient medical record in the Initial Evaluation.
â— Reviews necessary patient information including labs, medications (Pre and post hospital), History and Physical, therapy notes, ED notes, test results and progress notes.
â— Incorporates the patient/family care goals and preferences as much as possible into the transition of care planning and communicates these goals and preferences to the multidisciplinary team.
â— Incorporate clinical, social and financial factors into the transition of care plan.
â— Meets with patient/families to discuss realistic and appropriate discharge options and providers of post-hospital care.
â— Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to meet the individual needs of each patient
â— Identifies and collaborates with the interdisciplinary team and hospital operations to resolve potential barriers to transition of care plan achievement.
â— Collaborates with the multidisciplinary healthcare team daily in multidisciplinary rounds to efficiently communicate and facilitate high quality patient progression of care and transitions plans.
â— Evaluates the potential for readmissions throughout the patient stay through the monitoring of each patient’s readmission risk scores and coordinating readmission mitigation interventions.
â— Assures Social Work consults are completed for specialty services related to psychosocial needs, decision making needs for patients who lack capacity, patient/family adjustment needs and psychosocially complex cases.
â— Develops discharge plan with appropriate contingency plans throughout the hospital stay to enable adaptation to evolving patient care needs and ensure timely care coordination.
â— Escalates issues barriers to appropriate level of Care Management leadership
â— Assists with End of Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR.
â— Facilitates patient care conferences with multidisciplinary team as needed.
â— Establishes and documents, based on the predicted DRG and multidisciplinary team member’s input, Anticipated Date of Transition (ADOT) and destination and updates, as needed.
â— Actively participates in daily Multidisciplinary Rounds to review progression of care and discharge plan for all assigned patients
â— Proactively identifies patients who no longer meet medical necessity and escalates potential denials, documents avoidable days, and facilitates progression of care.
â— Collaborates with Utilization Management staff for collaboration on patient status changes and medical necessity discussions.
â— Ensures all patients on assigned unit(s) are moved timely and effectively to appropriate levels of care
â— Ensures reassessment of discharge needs provided anytime a patient’s condition changes and/or the circumstances impacting the provision of post-hospital care changes.
â— Ensures patient notifications are provided and documented in a timely manner for compliance: Important Medicare Letters (IML), Medicare Outpatient Observation Notice (MOON), Patient Choice, and Beneficiary Notice Letter (BNL).
â— Communicate with patient/family the possible need to pay for services out of pocket.
â— Ensures primary care physician identification and scheduling of follow-up PCP and specialist appointments for post-hospital follow up care.
â— Ensures discharge disposition accuracy and consistency in the EMR on all discharge patients.
â— Serves as a content expert regarding payor information and educates interdisciplinary team and patients/caregivers regarding payor requirements/barriers.
â— Maintains clinical competency and current knowledge of community resources, post-acute care providers and payor requirements to perform job responsibilities.
â— Participates in department and hospital Performance Improvement activities.
â— Provides necessary patient care coverage and assistance with other duties as assigned when needed.
â— Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization.
â— Participates in facility and department regulatory and certification preparations.
â— Social Work Care Manager serves as a preceptor
â— Social Work Care Manager participates in department education (bulletin or presentation) with topic and content approved by Facility CM Director
EDUCATION AND EXPERIENCE REQUIRED
â— Bachelor's in Social Work with health care related Masters or MSW
â— Minimum three (3) years experience in hospital/medical social work
EDUCATION AND EXPERIENCE PREFERRED:
â— Masters in Social Work
â— Care Management discharge planning experience
â— Knowledge of state and federal guidelines pertinent to care management
LICENSURE, CERTIFICATION, OR REGISTRATION PREFERRED:
â— Licensed Clinical Social Worker (LCSW)
â— ACM/CCM certification
The Social Work Care Manager intervenes with patients who have complex psychosocial needs, require assistance with eligibility determination for social programs, funding sources and qualify for community assistance from a variety of special assistance programs and agencies, and/or require assistance with transitions of care or discharge planning. In addition, offer crisis intervention to patients and families with psychosocial needs and coordinates and facilitates the development of a discharge plan of care for high-risk patient populations. This role will receive referrals for individuals from at-risk populations from interdisciplinary team members (including physicians, RN Care Managers, staff nurses, and other members of the care team).
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.