Social Worker-MSW-Patient Navigation-Unhoused Services

Default Work Shift:

Day (United States of America)

Hours:

40

Salary range:

$37.19 - $56.49

Schedule:

Full Time

Shift Hours:

10 Hour employee

Department:

Case Management Social Services

Job Objective:

Collaborates with hospital directors, charge nurses, care coordinators, physicians, nursing staff and the interdisciplinary team to ensure patients receive the best support, resources and discharge outcomes. Serves as a key resource for individuals experiencing homelessness by connecting patients to housing programs, healthcare services, mental health treatment, substance use treatment, public assistance and community-based support services.

Job Description:

Education:
Required: Master of Social Work (MSW)

Licensure/Certification:
Required: Service Prioritization Decision Assistance Tool (SPDAT) training within six (6) months of hire

Experience:
Preferred: Experience working with vulnerable populations, including individuals experiencing homelessness, mental health conditions, substance use disorders and complex medical needs; supervisory experience

Reports To: Manager or Director
Supervises: N/A
Ages of Patients: Pediatric, Adolescent, Adult, Geriatric
Blood Borne Pathogens: Minimal/ No Potential

Skills, Knowledge, Abilities:

Ability to deal concretely and psychologically with a variety of crises, Ability to establish and carry out complex plans of care for key diagnoses, Ability to exercise a high degree of initiative, judgment and discretion, Ability to listen, interact and communicate with a wide variety of cultural backgrounds and socioeconomic classes, Ability to manage complex discharge plans and long-term follow-up needs, Ability to organize efforts around helping clients have a positive experience, Ability to work effectively both independently and in multi-disciplinary team, Critical thinking skills, Knowledge of regulations, standards and legislation (local, state and federal) related to the continuum of care and patient transition, Problem solving skills to identify issues and formulate effective solutions, Self-starter; driven to take action without needing prompting, Strong crisis intervention, psychosocial assessment and advocacy skills, Strong knowledge of discharge planning, community resources, housing systems, payer/reimbursement practices and care coordination, Strong leadership, communication and relationship-building skills, Well developed psychosocial assessment and intervention skills, Written and verbal communication skills

Essential Responsibilities

1. Demonstrates compliance with Code of Conduct and compliance policies and takes action to resolve compliance questions or concerns and report suspected violations.
2. Completes psychosocial assessment of patients according to professional standards; documents using facts only without attitude, judgment or opinions; includes all telephone calls made with person’s name and phone number.
3. Conducts a discharge planning needs assessment and develops a discharge plan in conjunction with the Care Coordinator and the interdisciplinary team to meet desired goals for the next step in the continuum.
4. Seeks and develops collaborative relationships with community networks; acts as a bridge between Eisenhower Health and the public.
5. Manages communication, fosters positive relationships and ensures the organization meets patient needs with community resources, government services or institutional support. 
6. Maintains an electronic list serve to provide up-to-date information about resources and provides quarterly reports, as requested.
7. Creates and maintains a structured tracking system for patient follow-up ranging from three months to five years; this system will monitor patient progress after discharge, housing stability, connection to healthcare and behavioral health services, treatment compliance, community resource engagement, barriers to care, re-hospitalization risks and long-term service outcomes.
8. Communicates to patient/family, Care Coordinator and interdisciplinary team members the discharge options and plans for complex patients; communicates to patients their choices regarding discharge plans, and respects these choices as defined by federal, state and regulatory requirements.
9. Updates the Care Coordinator and team as to the status of the discharge plans; re-evaluates and revises the discharge plan as additional information is acquired and keeps patient/family and team informed to changes in the plan.
10. Works with Care Coordinator to obtain insurance approval for post acute services; maintains current knowledge and awareness of payer/reimbursement practices.
11. Coordinates the actual discharge plan, including transportation.
12. Coordinates utilization of patient and community resources to facilitate achievement of safe and effective discharge plan and accomplishment of goals.
13. Finalizes all discharge planning arrangements within 24 hours of discharge.
14. Ensures that any information that would be helpful, as appropriate, to facilitate continuity of care post-discharge, is communicated to post acute provider via discharge paperwork or via phone as per departmental documentation guidelines.
15. Follows up on discharge planning issues identified by nursing staff during off hours.
16. Develops strong relationships with community health resources to ensure appropriate patient access after discharge; completes timely referrals to post discharge providers, ensuring efficient patient flow and adherence to federal and regulatory requirements.
17. Screens patients, upon referral or according to high risk criteria for psychosocial needs; conducts psychosocial assessment when indicated to identify emotional, social and environmental issues impacting quality outcomes and efficient patient throughput.
18. Provides crises intervention, supportive counseling and advocacy to assist patients and/or family with adjustment associated with illness, hospitalization and/or alternative care placement; facilitates the decision making process in complex cases.
19. Communicates findings to Care Coordinator and other members of the interdisciplinary team and intervenes as appropriate in order to ensure a proactive approach to crisis intervention and efficient patient throughput.
20. Helps patients understand their rights in regards to patient choice, medical treatment, advanced directives and other related issues.
21. Helps patient/family understand, accept and follow medical recommendations within the context of self-determination.
22. Initiates appropriate referrals to the Ethics Committee, Physician Advisor, Risk Management or Legal Services, as appropriate.
23. Facilitates resolution of issues surrounding patient care in a compassionate manner, functioning as a patient advocate.
24. Serves as a resource to hospital staff and physicians concerning social issues (i.e., APS, CPS, Domestic Violence, the 5150 process, DPOA, mental health).
25. Ensures advance directives are in place and honored according to patient wishes.
26. Facilitates resource acquisition for the unfunded patient, as available.
27. Provides education to patient and families around issues related to adaptation to the patient’s diagnosis, illness, treatment, discharge plan and/or life situation.
28. Serves as a resource to members of the interdisciplinary team and patient/family regarding coverage issues, discharge options and community resources; participates in team meetings.
29. Documents according to hospital policy.
30. Collaborates with Care Coordinator, physicians, nursing and other healthcare disciplines to promote continuous process improvement, which results in efficiency, cost effectiveness, and the highest level of clinical excellence.
31. Calls in and writes APS and CPS reports when warranted, copies filed.
32. Performs 5150 assessments, locates facility and facilitates placement of 5150 patients.
33. Performs other duties as assigned.