Overview
The Care Coordination Social Worker Sr. (SW Sr ) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. Serves as an expert resource for complex patient and situations and serves as a consultant to the other care team members regarding patient's psychosocial and resource needs. In conjunction with the patient and physician, the SW Sr will assess, coordinate, and implement a timely, safe patient discharge plan to the next appropriate level of care. Overall, the role integrates and coordinates the patients transitional care plan into their individualized discharge plans based on needs and resources available.
Specific functions within this role include:
- Responsible for providing psychosocial assessments for patients to include timely and appropriate planning to advance the discharge plan.
- Assists in relaying information about community-based service offerings (e.g.-indigent care referrals and assistance, specialty care or post-acute placements, elder assistance, etc.) and offers guidance to patients/families to assist with multi-system factors that affect patient/family psychosocial dynamics.
- Serves as a specialist on issues related to psychosocial and discharge needs, end of life care planning, resource needs, etc. Will provide resource information necessary to aid patient/families in decision making up to and including support for end of life.
- Will partner and offer feedback to the RN Care Coordinator concerning complex social determinants of health issues, situational dynamics, and social needs.
- Will participate in orientation and precepting of new social work hires (as needed). The SW Sr will mentor other social workers in case reviews and discussion of difficult situations, to include, but not limited to assessing suicidal ideation, bereavement risk, social determinants of health, cultural or language barriers, abuse cases (both children and adult), along with many other scenarios.
- May have other duties assigned.
Responsibilities
Core Responsibilites and Essential Functions