JOB DESCRIPTION: Independently assess, coordinates and implements a timely, safe patient discharge plan to the appropriate level of care. Participates in interdisciplinary approach to patient care management. Works with complex patient populations who have high acuity chronic illnesses. Develops treatment plans, provides patient and family education and serves as a professional resource. Provides emotional support and psychosocial counseling to patients. Acknowledges and appropriately prioritizes referrals from interdisciplinary team members, patients, and families, with initial chart documentation entered within eight business hours of receipt of consult. Attends and actively participates in Triads and interdisciplinary team meetings in order to screen for high risk patients, obtain and share information, identify appropriate length of stay per DRG, advance the patients plan of care, identify and take action to resolve insurance, financial, and psychosocial barriers, and to coordinate safe and appropriate discharge to the proper level of care within the appropriate time frame. Maintains focus on the provision of quality service in a rapid and efficient manner in order to transition patients to the appropriate level of care within the time frame of the target length of stay. Possess knowledge of physiological components of various disease processes, basic medical terminology and procedures. Assess culturally diverse patients and members of their support system in order to identify potential needs, to determine appropriate level of care for discharge planning purposes and to identify necessary interventions and suicidal or homicidal risk. Evaluates family, home environment and financial situation in order to develop safe and viable plan of care. Provides patient and family counseling and education regarding discharge planning and community resources. Provides supportive counseling for patients, families, and significant others who are experiencing anxiety or stress due to illness, injury or physical limitations, adjustment issues as it relates to changing roles in family or loss of income. Takes an active role in the coordination and facilitation of goal oriented family meetings in support of the patient and family centered care philosophy. Evaluates, coordinates and acts in accordance with current laws and hospital policies in reporting targeted populations (suspected child/disabled adult/older abuse or neglect). Documents in an accurate, timely and thorough manner in accordance with departmental policy. Records assessment, ongoing contacts, and final discharge plan including level of care to which patient is being transferred. Completes all necessary paperwork and computer documentation in order to Assure continuity of care, accurate reimbursement to the organization, and compliance with regulatory requirements. Obtains and communicates information through timely and efficient use of available computer applications (Healthquest, EeMR, Groupwise, Social Services Lotus Notes Database and the internet). Reviews and interprets Length of Stay Data Reports and Patient Satisfaction Survey Reports. Performs other duties as required.
MINIMUM QUALIFICATIONS: Master's degree in Social Work from an accredited school of Social Work. One year of medical social work experience in an acute care setting. Positions in this classification require license in the state of Georgia (LMSW). Must have working knowledge of software applications.
PHYSICAL REQUIREMENTS (Medium): 20-50 lbs; 0-33% of the work day (occasionally); 11-25 lbs, 34-66% of the workday (frequently); 01-10 lbs, 67-100% of the workday (constantly); Lifting 50 lbs max; Carrying of objects up to 25 lbs; Occasional to frequent standing & walking, Occasional sitting, Close eye work (computers, typing, reading, writing), Physical demands may vary depending on assigned work area and work tasks.
ENVIRONMENTAL FACTORS: Factors affecting environment conditions may vary depending on the assigned work area and tasks. Environmental exposures include, but are not limited to: Blood-borne pathogen exposure Bio-hazardous waste Chemicals/gases/fumes/vapors Communicable diseases Electrical shock, Floor Surfaces, Hot/Cold Temperatures, Indoor/Outdoor conditions, Latex, Lighting, Patient care/handling injuries, Radiation, Shift work, Travel may be required. Use of personal protective equipment, including respirators, environmental conditions may vary depending on assigned work area and work tasks.