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Hospital Clinical Social Work/Social Services involve identifying patientÃ¢â‚¬â„¢s specific needs, and coordinating linkage with community agencies, in-home services, and institutional short-term and long-term placement for continuing care.
Assists the patient, family/guardian and all members of the healthcare team with needs assessment and discharge planning process. Contributes to the monitoring of the quality and appropriateness of patient care delivered. Responsible for the reporting and analysis of patient satisfaction survey data. Provides safe and supportive environment for all patients, families and coworkers. Promotes and provides for optimal patient outcomes through the use of Social Services scope of practice and scope of services. The scope of services are hospital-wide/organizational, whereas, services may involve patient/family interventions in any inpatient setting or outpatient services area, including the Emergency Department.
Strives to promote patient and family wellness, improve care outcomes, and access to appropriate hospital and community resources among the patient population service area, including patients with complex health and financial needs.
Provides patient family advocacy, discharge planning coordination, and psychosocial intervention for identified high risk patients and or other patient case referrals, as necessary.
PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:
Â· Strong knowledge regarding Social Services and Care Management processes in preadmission, emergency department, outpatient/ambulatory services, and hospital acute short term care, as well as post-acute care services.
Â· Is responsible for providing crisis intervention and/or community linkage for patients and families who are experiencing significant emotional, social, environmental, or financial stress due to hospitalization, acute, chronic, or terminal illness and/or who need help in meeting their continuing care needs.
Â· Evaluates all Social Service referrals and identifies discharge planning needs, to include documentation of the patient discharge assessment in accordance with established guidelines and or hospital polices and processes; services to patients in the hospital acute care setting, outpatient services, and outpatient/emergency department.
Â· Responsible for the facilitation and compliance in relations to CMS or state specific requirements or guidelines for PASSR forms for Skilled Nursing/nursing home placement.
Â· Initiate and complete the level 1 screen for serious mental illness and/or intellectual disability for all skilled nursing facility placement.
Â· Systematically gathers pertinent psychosocial data for high risk hospital inpatients whereby patient and family psychosocial needs can be identified, and an appropriate discharge plan can be developed.
Â· Coordinates with physicians, case management staff, and other clinical staff in assisting patients and their families in understanding, accepting, and following medical recommendations. Identifies barriers to continuity of care, and negotiates with insurances/third party payers to offer the patient appropriate level of care and services.
Â· Assists the patient/family in investigating eligibility or application process for hospital charity, Medicaid or SSI through HHS; a case referral to hospital financial counselor services, when necessary.
Â· Participates in patient, and or patient/family conferences within the hospital setting.
Â· Provides counseling, advocacy, and linkage to post- acute external care resources.
Â· Facilitates the restoration of patients to social and health adjustment within their capability.
Â· Refers patients and families to community-based support groups, when appropriate; leader for hospital setting support groups.
Â· Incorporates social, emotional and spiritual aspects of care into the patients plan.
Â· Acknowledges and addresses the impact of cultural values and beliefs, including view on illness, disability and death and incorporates into the assessment and plan of intervention.
Â· Demonstrates competency in knowledge base of community resources to address identified needs.
Â· Coordinates end or life palliative, and or pastoral care services as appropriate for the terminal patient or end stage patient.
Â· Performs patient/family counseling regarding options for post-acute care such as acute rehabilitation and long-term acute care hospitals, skilled nursing units, home health care, hospice referrals, assisted living or other community services and support groups.
Â· Measures change in patient and family psychosocial coping and decision-making and communicates progress and/or barriers to clinical team and documents in medical record.
Â· Counsels patients and their families to reduce anxieties or fears and promotes patient/family understanding and cooperation with recommended treatment plans. Assists with and or interprets Advance Directives information to the patient/family or staff when consulted
Â· Assists families with problems and care needs identified during pre-admission, in emergency department, outpatient services, during hospitalization and in planning discharge and post-hospital care plans. Performs high-risk screens and post-acute follow-up phone calls, when appropriate
Â· Encourages patient/family/significant-other to be involved in the care plan. Mediates with nursing and clinical staff to represent and seek solutions to patient/family/ significant others concerns, patient rights, or protective service issues and agency referrals. Refers to the Medical Center Ethics Committee when patient's wishes and the treatment plan are in conflict or when objective mediation seems to be indicated to promote patient care, patient rights, or Advance Directives; Member of the Ethics Committee.
Â· Prepares and maintains accurate documentation record in the medical chart for each discharge planning consult, case review, assessments, appropriate patient and family involvement in care choices, environmental and functional status needs, family and caregiver relationships, and easily-discernable final disposition referrals. Enters relevant case assessments, and referral information into the Social Work Information Management System/E.H.R.
Â· Intervenes in the social, economic, environmental, or emotional problems hindering the patient from receiving safe and optimal continuity of care. Facilitates the removal of patients from imminent danger situations within the parameters and protocols provided through regulatory agencies.
Â· Provides crisis intervention and appropriate protective agency and law enforcement referrals/staff advisement as regulations apply. Advises staff in making appropriate verbal and written protective service and law enforcement referrals. Follows up as appropriate to advocate, provide expertise in providing an assessment, intervention, support , and/or help promote protective service victim referrals in cases of sexual assault and rape, child and adult abuse, Complex crisis with mental health, substance abuse, neglect and financial exploitation, and domestic violence.
Â· Complete and initiate all documents and file appropriate paperwork for an ex-parte at the county courthouse, if, or when appropriate.
Â· May be consulted to advise staff on treatment of minors; portable DNR or POST orders; EMTALA regulations; medical/legal issues; Medical Center departmental policies on reporting of abuse, neglect, domestic violence; age-specific treatment or referral issues; and state and federal statutes which impact patient care.
Â· LCSW Scope of Practice Only: Able to testify in court regarding a patientÃ¢â‚¬â„¢s mental health status, and psychological diagnosis as determined by DSM-5 screening.
Â· Proactive participation in unit continuity of care meetings, interdisciplinary rounds, Medical Center Committees, C.Q.I. teams and may serve as a Medical Center representative on various community service boards as authorized by the department leader or authorized designee.
Â· Collaborates with the Case Managers, physicians, and or multidisciplinary team daily, and address psychosocial and financial barriers that may impede progress throughout the patient care continuum, impact or delay the patients discharge plan, or interfere with medical compliance.
Â· Advocates for the patient and performs discharge planning/after care coordination. Supports efforts to decrease hospital readmissions when possible and return patient to the community with appropriate resources. Provides patient/family education regarding psychosocial aspects of illness.
Â· Utilize appropriate measures to promote and maintain patient safety.
KNOWLEDGE AND SKILLS PREFERRED:
Work experience in an acute/medical or mental health setting ( 2 years minimum) or
Community-based field worker experience in the field of Social Services for CPS/APS systems (2 years minimum
EDUCATION AND EXPERIENCE REQUIRED:
Â· Masters of Social Work
Â· Licensed in Clinical Social Worker
EDUCATION AND EXPERIENCE PREFERRED:
Â· Minimum of three (3) years of MSW, Licensed Clinical Social Work experience, hospital and or community-based
LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:
Â· Florida State accredited/licensure and certification(s): MSW, LCSW
Â· MSW Degree in Social Work Ã¢â‚¬âœaccredited school of social work
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.