PMC Medical
Psychosocial Assessment and Interventions:
• On the basis of preliminary risk screening, assesses patients and family’s psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope.
• Appropriately documents in medical record those patients identified as high risk for readmission.
• 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.
• Provides intervention in cases involving child abuse/neglect, domestic violence, elder abuse, institutional abuse, and sexual assault.
• Serves as a resource person and provided counseling and intervention related to treatment decisions and end-of-life issues.
Discharge Planning:
• Participates in discharge planning activities for complex patients, in order to ensure a timely discharge and to provide appropriate linkage with post-discharge care providers.
• Deals with families exhibiting complex family dynamics that impact directly on patient care and discharge.
• Communicates with healthcare team regarding the discharge planning status of all patients referred by them.
• Assists RN Case Managers or appropriate team members with discharge planning activities as requested.
• Provides consultation to RN Case Manager or appropriate team members when coordination with significant or intensive community resources is necessary to achieve desired treatment outcomes.
• Receives referrals for complex patient problem resolution from RN Case Managers or care team members.
• Screens and coordinates referrals to the next level of care, SNF, LTAC, Hospice, and Rehab. Validates discharge criteria for patient and families and notifies RN Case Managers of newly-identified resources or change in previously-identified resources.
• Educations patient/family and physician regarding post-acute options and addresses issues of choice.
• Patient and Family Support in Legally Complex Cases:
• Provides intervention in child abuse/neglect, domestic violence, guardianship (temporary/permanent), foster case, adoption, mental health placement, advance directives, adult/elderly abuse, child protection and sexual assault.
• Ensures safe care to patients adhering to policies, procedures, and standards within budgetary specifications, including time management, supply management, productivity, and accuracy of practice.
• 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.
• Actively participates in care conferences and multidisciplinary rounds.
• Advocates for patient and family empowerments and independence to make autonomous health care decisions and access needed services within the health care system.
• Actively participates in clinical performance improvement activities as assigned.
• May provide supervision of Social Worker interns, MSW’s with less than 4,000 hours of hospital experience, ensuring requirements mandated by the State of Michigan. Provides mentorship to all levels of Social Work in current social trends and practice.
• Maintains documentation of the Case Work process in the patient’s medical record to include problem statement, plan, interventions, and outcomes. Documents progress with active placement activities at least three (3) times/week. Records case work volume statistics as required by departmental leadership.
• Arranges for and participates in coverage during short, long, and/or unexpected absences of self and other Case Management staff.
• Demonstrates knowledge of and supports hospital mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality statements, corporate compliance plan, customer service standards, and the code of ethical behavior.
EDUCATION
Master’s prepared Social Worker with current licensure to practice medical social work in the state of Michigan (LMSW). If LLMSW, must obtain LMSW designation within 6 months of qualification to sit for exam.
REQUIRED EXPERIENCE:
Two (2) years’ experience in a short term acute care hospital setting preferred.
Prior Case Management or health finance experience preferred.
Experiential knowledge of the post hospital place process preferred.