Social Worker-MSW-Patient Navigation-Unhoused Services-Case Management Social Services

Job Objective:

Collaborates with hospital directors, charge nurses, care coordinators, physicians, nursing staff and the interdisciplinary team to ensure patients receive the best support, resources and discharge outcomes. Serves as a key resource for individuals experiencing homelessness by connecting patients to housing programs, healthcare services, mental health treatment, substance use treatment, public assistance and community-based support services.

Essential Responsibilities:

• Demonstrates compliance with Code of Conduct and compliance policies and takes action to resolve compliance questions or concerns and report suspected violations.
• Completes psychosocial assessment of patients according to professional standards; documents using facts only without attitude, judgment or opinions; includes all telephone calls made with person’s name and phone number.
• Conducts a discharge planning needs assessment and develops a discharge plan in conjunction with the Care Coordinator and the interdisciplinary team to meet desired goals for the next step in the continuum.
• Seeks and develops collaborative relationships with community networks; acts as a bridge between Eisenhower Health and the public.
• Manages communication, fosters positive relationships and ensures the organization meets patient needs with community resources, government services or institutional support. 
• Maintains an electronic list serve to provide up-to-date information about resources and provides quarterly reports, as requested.
• Creates and maintains a structured tracking system for patient follow-up ranging from three months to five years; this system will monitor patient progress after discharge, housing stability, connection to healthcare and behavioral health services, treatment compliance, community resource engagement, barriers to care, re-hospitalization risks and long-term service outcomes.
• Communicates to patient/family, Care Coordinator and interdisciplinary team members the discharge options and plans for complex patients; communicates to patients their choices regarding discharge plans, and respects these choices as defined by federal, state and regulatory requirements.
• Updates the Care Coordinator and team as to the status of the discharge plans; re-evaluates and revises the discharge plan as additional information is acquired and keeps patient/family and team informed to changes in the plan.
• Works with Care Coordinator to obtain insurance approval for post acute services; maintains current knowledge and awareness of payer/reimbursement practices.
• Coordinates the actual discharge plan, including transportation.
• Coordinates utilization of patient and community resources to facilitate achievement of safe and effective discharge plan and accomplishment of goals.
• Finalizes all discharge planning arrangements within 24 hours of discharge.
• Ensures that any information that would be helpful, as appropriate, to facilitate continuity of care post-discharge, is communicated to post acute provider via discharge paperwork or via phone as per departmental documentation guidelines.
• Follows up on discharge planning issues identified by nursing staff during off hours.
• Develops strong relationships with community health resources to ensure appropriate patient access after discharge; completes timely referrals to post discharge providers, ensuring efficient patient flow and adherence to federal and regulatory requirements.
• Screens patients, upon referral or according to high risk criteria for psychosocial needs; conducts psychosocial assessment when indicated to identify emotional, social and environmental issues impacting quality outcomes and efficient patient throughput.
• Provides crises intervention, supportive counseling and advocacy to assist patients and/or family with adjustment associated with illness, hospitalization and/or alternative care placement; facilitates the decision making process in complex cases.
• Communicates findings to Care Coordinator and other members of the interdisciplinary team and intervenes as appropriate in order to ensure a proactive approach to crisis intervention and efficient patient throughput.
• Helps patients understand their rights in regards to patient choice, medical treatment, advanced directives and other related issues.
• Helps patient/family understand, accept and follow medical recommendations within the context of self-determination.
• Initiates appropriate referrals to the Ethics Committee, Physician Advisor, Risk Management or Legal Services, as appropriate.
• Facilitates resolution of issues surrounding patient care in a compassionate manner, functioning as a patient advocate.
• Serves as a resource to hospital staff and physicians concerning social issues (i.e., APS, CPS, Domestic Violence, the 5150 process, DPOA, mental health).
• Ensures advance directives are in place and honored according to patient wishes.
• Facilitates resource acquisition for the unfunded patient, as available.
• Provides education to patient and families around issues related to adaptation to the patient’s diagnosis, illness, treatment, discharge plan and/or life situation.
• Serves as a resource to members of the interdisciplinary team and patient/family regarding coverage issues, discharge options and community resources; participates in team meetings.
• Documents according to hospital policy.
• Collaborates with Care Coordinator, physicians, nursing and other healthcare disciplines to promote continuous process improvement, which results in efficiency, cost effectiveness, and the highest level of clinical excellence.
• Calls in and writes APS and CPS reports when warranted, copies filed.
• Performs 5150 assessments, locates facility and facilitates placement of 5150 patients.
• Performs other duties as assigned.

Essential Skils:

• Strong knowledge of discharge planning, community resources, housing systems, payer/reimbursement practices and care coordination
• Strong crisis intervention, psychosocial assessment and advocacy skills
• Critical thinking skills
• Self-starter; driven to take action without needing prompting
• Problem solving skills to identify issues and formulate effective solutions
• Knowledge of regulations, standards and legislation (local, state and federal) related to the continuum of care and patient transition
• Written and verbal communication skills
• Ability to establish and carry out complex plans of care for key diagnoses
• Ability to exercise a high degree of initiative, judgment and discretion
• Ability to listen, interact and communicate with a wide variety of cultural backgrounds and socioeconomic classes
• Ability to deal concretely and psychologically with a variety of crises
• Ability to organize efforts around helping clients have a positive experience
• Strong leadership, communication and relationship-building skills
• Ability to manage complex discharge plans and long-term follow-up needs
• Ability to work effectively both independently and in multi-disciplinary team
• Well developed psychosocial assessment and intervention skills