The Social Worker plans, organizes and provides social services to patients and families. They assess the patient's family/social support system and identify any psychosocial/actors which may impact the patient's hospitalization or discharge. They assist in the coordination of patient care through consultation with all other members of the healthcare team. They strive to identify resources that will facilitate a transition to assure completion of the continuum of care. This position requires the full understanding and active participation in fulfilling the Mission of CHRISTUS St. Frances Cabrini Rehabilitation Unit. Coordinates weekly team conference for all patients and facilitates interdisciplinary team functioning.
Action Oriented -- Taking on new opportunities and tough challenges with a sense of urgency, high energy and enthusiasm.
Customer Focus -- Building strong customer relationships and delivering customer-centric solutions.
Communicates Effectively -- Developing and delivering multi-mode communications that convey a clear understanding of the unique needs of different audiences.
Decision Quality -- Making good and timely decisions that keep the organization moving forward.
Collaborates -- Building partnerships and working collaboratively with others to meet shared objectives.
Nimble Learning -- Actively learning through experimentation when tackling new problems, using both successes and failures as learning fodder.
Demonstrates Self-Awareness -- Using a combination of feedback and reflection to gain productive insight into personal strengths and weaknesses.
Goals -- Completes quarterly goals
Delivering the Mission -- Performs duties as defined in this job description and demonstrates mastery of role
1. Healthstream (HLC) modules completed by assigned date.
2. Complete Associate Self-evaluation and give to Supervisor by assigned date.
3. Attend at least 2 Quarterly Associate Forums.
4. Attendance at 50% of Monthly department meetings and educational inservices.
1. Assess the psychosocial, high risk, cultural and discharge needs of the patient and family.
2. Interviews patient/family to determine any social barriers to care and discharge.
3. Complete psychosocial assessment on all high risk populations.
4. Correctly differentiate between patient's who have adequate social support systems verses those who may be at risk for neglect.
5. Assist patients and families with development of satisfactory discharge plan.
6. Provide supportive counseling to patients/families to increase their understanding of their illness/trauma.
7. Provide supportive counseling to educate patient/family on available community resources.
8. Incorporate cultural and ethnic factor into delivery of services.
9. Responds to all referrals made for social services.
10. Effectively communicate patient's psychosocial needs to physicians and health care team.
11. Respects patient's rights, especially right of self determination, when helping patient develop discharge plan.
12. Is knowledgeable about and able to educate patient's, families and staff regarding Advance Directives.
13. Demonstrates knowledge of appropriate process and forms used to formulate Advance Directives.
14. Responds to all referrals requesting assistance with education and formulation of Advance Directives.
15. Communicates to nursing staff and physician when patient has completed an Advance Directive.
16. Facilities communication between physician, family and health care team to assure the patient's Advance Directives is honored.
17. Develops and maintains knowledge of and relationships with community resources.
18. Maintains a record of available community resources.
19. Uses networking skills to learn about any new programs in the community
20. Shares information about community resources with patients, families, staff, and physicians.
21. Maintains good working relationships with community resources through effective communication.
22. Serves as a board member of community resources if asked.
23. Incorporates Social Work assessment into the multidisciplinary care and management of the patient/family.
24. Communicates effectively with psychosocial and health care team.
25. Coordinates social work interventions with other evolved disciplines.
26. Involves other health team members as necessary.
27. Activity participates in multidisciplinary care conferences.
28. Demonstrates the ability to utilize strategies of conflict resolution and crisis management.
29. Utilizes effective intervention strategies when a conflict arises between a patient/family and the health care team.
30. Serves as a liaison for non-violent confrontations in a neutral role as the patient advocate.
31. Is able to assess when a conflict is escalating to an abusive/violent level and calls for assistance from the Security Department to maintain a safe environment.
32. Provides crisis management to families during an external or internal disaster.
33. Assures the rights of the patient/family are respected and maintained.
34. Allows for privacy and modesty when delivering services.
35. Identifies self by name and explains role to patient/family.
36. Understands role of and how to access the Ethics Committee.
37. Reports suspected cases of abuse/neglect to the appropriate agency.
38. Assures that patient understands they have the right to refuse services offered.
39. Demonstrates the ability to recognize, report and fulfill specific responsibilities related to abuse of a child, abuse of an adult, and victims of domestic violence.
40. Is knowledgeable about indicators of child abuse, adult abuse and domestic violence.
41. Responds to all referrals and completes a psychosocial assessment using the abuse reporting form.
42. Reports the abuse to the appropriate agency.
43. Provides information to victims of domestic violence about supportive services available within the community.
44. Refer victims of domestic violence to the appropriate agency, if they are in agreement with the referral.
45. Demonstrates the ability to assess and provide referrals to patients who are in need of psychiatric care.
46. Able to assess if the patient is in need of psychiatric care out-patient verses in-patient.
47. Understands the process for transferring a patient to a psychiatric facility.
48. Understanding the process of implementing a Physician's Emergency Commitment for patients who are a danger to self and others and is an involuntary patient.
49. Communicates only to the persons who need to know the nature of the patients psychiatric illness.
50. Demonstrates knowledge of department specific policies and procedures.
51. Refer to the policy manual when unsure of specific procedures.
52. Completed Department Specific Annual Competency Checklist.
54. Works with the Rehab Case Manager to achieve the following:
a. Displays a knowledge of various levels of care and the ability to distinguish the appropriate level for each patient
b. Displays a knowledge of Medicare regulations and coverage
c. Communicates effectively to third party payers
d. Participates in and facilitates the weekly interdisciplinary team conference
Individual Program Planning
a. Promotes patient/family involvement in the planning process
b. Reviews the interdisciplinary treatment plan with the patient/family following the interdisciplinary team conference
c. Assures that appropriate services are provided to facilitate meeting the patient's goals
d. Works with the interdisciplinary team to respond to the needs and preferences of the patient/family
e. Communicates effectively the patient's current staus to third party payers as indicated
f. Meets with individual disciplines as needed
g. Documents effectively the patient's progress in the electronic medical record
h. Ensures protection of the patient rights and confidentiality
a. Collaborates with interdisciplinary team members to ensure an organized plan of discharge and follow-up referrals for each person served
b. Coordinates discharge team conferences
c. Promotes patient/family involvement and maintains ongoing communication of discharge and referral plans
d. Coordinates activities to obtain durable medical equipment needed for discharge with all appropriate parties
e. Documents discharge, referral and follow-up processes as appropriate in the electronic medical record
a. Contacts the patient/family within five working days of discharge to confirm status of post-discharge recommendations and documents findings in the electronic medical record
b. Requests that the patient/family complete the patient satisfaction quesitonnaire during the follow-up contact
Graduate from an accredited university with a Master's Degree in Social Work.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.