Assesses patient’s and family’s psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, assisting those coping with adjusting to significant life transitions
Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability; accesses and mobilizes family/community resources to meet identified needs
Serves as a resource to provide information and intervention related to treatment decisions, terminal illnesses and end-of-life issues
Provides grief counseling and crisis intervention skills
Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the healthcare system
Provides de-escalation services for patient/family as appropriate
Provide Motivational Interview techniques for patients with substance use and addictive disorders
Provides patient/family education, adjustment-to-illness counseling, grief counseling and crisis intervention
Provides education to patients/families/caregivers regarding resource options and coping with diagnosis, treatment and prognosis
Works in collaboration with hospital and community agencies to obtain needed services and resources for patients/families/caregivers
Receives referrals for psychosocial complex needs from the health care team.
Provides assessment and reporting interventions in child abuse/neglect, domestic violence, adult/elderly abuse, child protection, sexual assault, and human trafficking as appropriate.
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.
Provides consult services for foster care and adoptions.
Assists the health care team in the patient assessments and placements for mental health services.
Facilitates full team discussion including patient and family when ethical dilemmas arise.
Promotes the understanding and use of advanced directives and ensures patient preference and care goals are followed
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.
Reviews necessary patient information including labs, medications (Pre and post hospital), History and Physical, therapy notes, ED notes, test results and progress notes.
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.
Incorporate clinical, social and financial factors into the transition of care plan.
Meets with patient/families to discuss realistic and appropriate discharge options and providers of post-hospital care.
Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to meet the individual needs of each patient
Identifies and collaborates with the interdisciplinary team and hospital operations to resolve potential barriers to transition of care plan achievement.
Collaborates with the multidisciplinary healthcare team daily in multidisciplinary rounds to efficiently communicate and facilitate high quality patient progression of care and transitions plans.
Evaluates the potential for readmissions throughout the patient stay through the monitoring of each patient’s readmission risk scores and coordinating readmission mitigation interventions.
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.
Develops discharge plan with appropriate contingency plans throughout the hospital stay to enable adaptation to evolving patient care needs and ensure timely care coordination.
Escalates issues barriers to appropriate level of Care Management leadership
Assists with End of Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR.
Facilitates patient care conferences with multidisciplinary team as needed.
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.
Actively participates in daily Multidisciplinary Rounds to review progression of care and discharge plan for all assigned patients
Proactively identifies patients who no longer meet medical necessity and escalates potential denials, documents avoidable days, and facilitates progression of care.
Collaborates with Utilization Management staff for collaboration on patient status changes and medical necessity discussions.
Ensures all patients on assigned unit(s) are moved timely and effectively to appropriate levels of care
Ensures reassessment of discharge needs provided anytime a patient’s condition changes and/or the circumstances impacting the provision of post-hospital care changes.
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).
Communicate with patient/family the possible need to pay for services out of pocket.
Ensures primary care physician identification and scheduling of follow-up PCP and specialist appointments for post-hospital follow up care.
Ensures discharge disposition accuracy and consistency in the EMR on all discharge patients.
Serves as a content expert regarding payor information and educates interdisciplinary team and patients/caregivers regarding payor requirements/barriers.
Maintains clinical competency and current knowledge of community resources, post-acute care providers and payor requirements to perform job responsibilities.
Participates in department and hospital Performance Improvement activities.
Provides necessary patient care coverage and assistance with other duties as assigned when needed.
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.
Participates in facility and department regulatory and certification preparations.
Social Work Care Manager serves as a preceptor
Social Work Care Manager participates in department education (bulletin or presentation) with topic and content approved by Facility CM Director
What you will need:
EDUCATION AND EXPERIENCE REQUIRED:
Bachelor's in Social Work with health care related Masters or MSW
Minimum three (3) years experience in hospital/medical social work
EDUCATION AND EXPERIENCE PREFERRED:
Masters in Social Work
Care Management discharge planning experience
Knowledge of state and federal guidelines pertinent to care management
KNOWLEDGE AND SKILLS REQUIRED:
Excellent interpersonal communication and negotiation skills
Critical thinking and problem-solving skills
Psychosocial assessment skills
Customer service skills
Ability to work and communicate with people of all social, economic, and cultural backgrounds; be flexible, open-minded and adaptable to change
Effective organizational skills
Computer proficiency with Outlook e-mail and electronic medical records
Flexible in a complex and changing healthcare environment
Understanding of pre-acute and post-acute venues of care and post-acute community resources
Maintains a current working knowledge of services available in the local community, particularly services available to patients with limited or non-existent payment resources
Strong interview, assessment, and organizational skills
Data analysis skills
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).
The Social Work Care Manager, in collaboration with the patient/family, care manager nurses, nurses, physicians and the interdisciplinary team, ensures patient-centered care coordination through the continuum of care. The Social Work Care Manager ensures efficient and cost-effective care through appropriate resources monitoring and clinical care escalations. The Social Worker is under the general supervision of the Care Management Supervisor or Manager and is responsible for patient evaluations of post-hospital needs; development of a transition of care plans and initiation of the implementation of the transitions of care plans prior to the discharge of the patient. The Social Work Care Manager is responsible for optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, readmission prevention and length of stay management. The Social Work Care Manager communicates daily with the interdisciplinary team during daily multidisciplinary rounds. Care coordination, discharge planning, transitions of care planning and are core competencies of this role. The Social Work Care Manager facilitates the collaborative management of patient care across the continuum, intervening to remove barriers to timely and efficient care delivery and reimbursement. The Social Work Care Manager provides education to nurses, physicians and the interdisciplinary team on issues related to utilization of resources, medical necessity, CMS CoP for Discharge Planning and care coordination. The Social Work Care Manager is knowledgeable of post-hospital care and services available to the patient including, but not limited to the following: Home Health, Infusion Services, Durable Medical Equipment, Palliative Care, Hospice, Outpatient Services, Transitions of Care Clinics, Transitional Care supportive programs and clinics, follow up appointments, Skilled Nursing Facilities, Rehabilitation Services and Facilities and Community-based Organizations. The Social Work Care Manager adheres to departmental and system goals, objectives, policies and procedures and ensures quality
AdventHealth Greater Orlando (formerly Florida Hospital) is one of the largest faith-based health care providers in the United States. For 150 years, we have carried on a tradition of providing whole-person care that not only addresses patients' physical ailments, but also supports their emotional and spiritual well-being. We demonstrate the same level of compassion and care for our employees as well, doing all that we can to help them realize their full potential – both personally and professionally.