Social Service Coordinator - Discharge Services - Days

Position Function: Under the direction of the Manager of Care Management, using the social work process, works with patients, families, staff and outside agencies to address the psychosocial needs of patients and families. These services would include an assessment of patient needs, development and implementation of appropriate interventions and a comprehensive discharge plan. All services provided are designed to assist the patient/families in coping with physical, social, emotional and economic issues related to their illness, treatment, hospitalization and/or discharge. Post discharge follow-up of the care provided is also an integral part of this position.

Essential Functions and Responsibilities

1. Maintains respect for patient rights and privacy, and serves as a patient advocate.
2. Performs all duties in accordance with hospital policies and procedures regarding patient care, with special attention to isolation procedures.
3. Integrates ethical judgement and technical skills and works within the established hospital policies and procedures and legal guidelines.
4. Interviews patients/families in a manner that demonstrates empathy, focusing on the patient's home environment, family relationships, health history and patients perception of care needs.
5. Assesses patient/family level of knowledge, understanding and readiness to learn about the illness/disability, its implications and care required.
6. Evaluates the patient with regard for unique age/population-related factors and developmental stages and distinguishes between expected psychosocial changes and those indicative of illness or maladaption.
7. Explains interventions to older patients by adapting communication style (eg., lower pitch of voice, short and simple sentence structure, nonverbal gestures, etc.) thereby reducing their anxiety and enhancing their understanding of recommendations provided.
8. Demonstrates ability to prioritize workload in accordance with patient needs and in accordance with departmental goals and objectives.
9. Assists in revision of or formation of new goals and objectives for the department.
10. Performs initial patient/family assessment within 24 hours during the work week, and as soon as possible following a week-end or holiday.
11. Assumes responsibility and accountability for identifying patient's needs as part of psychosocial assessment and initiates action plans to accomplish established goals based on this assessment.
12. Factors to consider in patient's multidisciplinary assessment include: Identifying information; Premorbid functioning; Physical structure of dwelling; Caregiver support system; Patient/family goals; Psychosocial assessment (including patient/family education needs); Recommendations.
13. Analyzes data to determine therapeutic dynamics of the patient as an individual with his/her family system and integrates information as part of the patient's/family's counseling sessions.
14. Participates in interdisciplinary rounds and conferences on regular basis and provides input in patient's plan of care, communicating judgments based on the patient's assessment and observation of any pertinent changes in the patient's condition.
15. Researches resources available to meet the social, economic and emotional needs of the patient.
16. Provides individual counseling, as indicated.
17. Participates in conferences on behalf of patients/families and assists them in understanding and accepting their diagnosis and/or treatment options.
18. Correlates patient care with other hospital departments and the medical staff to develop comprehensive discharge plan.
19. Correlates the development of patient's discharge plan with available resources, generates referrals to community agencies and arranges for patient/family teaching as needed, encouraging participation in support groups, if appropriate.
20. Develops and maintains positive interagency and community service provider relationship.
21. Documents pertinent information concerning patient's needs and/or interventions in the meditech system and focuses on real-time documentation.
22. Revises documentation, as circumstances warrant, keeping patient information current and up to date.
23. Serves as a resource person for staff and others.
24. Communicates information and judgments, based on interaction with the patient/family, and keeps appropriate people aware of pertinent changes or problems in a patient's condition, as observed.
25. Develops self and enhances practice skills by participation in continuing education events and/or monthly social service meetings and those unit based programs for education.
26. Completes departmental required competencies.
27. Identifies system issues in the organization preventing achievement of departmental or hospital goals. Assists in communication and actions to decrease these barriers and actively engage in performance improvement initiatives, as designated by leadership.
28. Identifies and reports all occurrences of physical, emotional or sexual abuse/or neglect in compliance with State mandates and laws.
29. Works with physicians, staff from other departments, utilization management, third party payers and families to facilitate transition of the patient throughout the continuum at the appropriate level of care.
30. Completes required reports on time.

Qualifications and Standards

Education: Graduate from an accredited school with a Bachelors of Social Work degree or other related field, and with a Masters Degree in Social Work preferred.
Informal Education: As appropriate to maintain current knowledge and skill. Must show evidence of continuing education as related to social work practice skills and/or hospital required in services.

Experience: Experience applying customer service behaviors and communication skills required. A minimum of two years social work practice in health care environment or related field, preferred. Must demonstrate knowledge of social work skill sets that include competency in assessment, development of discharge plan, implementation of that plan and evaluation of services provided. Demonstration of positive interpersonal skills and the knowledge of and ability to relate positively to community agencies is required. Must also demonstrate ability to understand team concept as a member of healthcare team (including physicians, allied health professionals and payers) and provide advocacy role on behalf of patients and families. Proficiency in Meditech, GroupWise, Microsoft Word and other computer application inherent in electronic medical record keeping is required.

Certifications/Licensure: CPR certification required. Professional licensure not required, but is encouraged.