MEDICAL SOCIAL WORKER

Bargaining Unit: Seafarers International Union (SIU Allied Health)

Salary: $50,000-$75,000 (Salary commensurate with experience)

POSITION SUMMARY

The Medical Social Worker 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 funds and agencies.  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, Case Managers, staff nurses and other members of the care team).

 

The Social Worker must be able to demonstrate knowledge and skills necessary to provide care appropriate to the patient served.  Must demonstrate knowledge of the principles of growth and development as it relates to the different life cycles.  Specific age groups that are served by this position and listed below.

 

POSITION RESPONSIBILITIES/DUTIES

 

1.       Current and valid license to practice as a Licensed Clinical Social Worker (LSW or MSW) in the state of the Virgin Islands.

2.       One or Two years experience of hospital social work and protective service experience

3.       Strong interview, assessment, organizational and problem solving skills.

4.       Ability to identify appropriate community resources on assigned caseload and to work collaboratively with patients, families, and multidisciplinary team and community agencies to achieve desired patient outcomes.

5.       Possesses excellent interpersonal communication and negotiation skills in interactions with patients, families, physicians and health care team colleagues.

6.       Strong analytical and PC skills.  Exposure and/or experience in pre-acute and post-acute care, as well as community resources.

7.        Ability to work independently as well as to develop collaborative relationships with physicians, families, patients, interdisciplinary team and other community agencies.

8.       Excellent communication and negotiation skills.

9.       Ability to analyze, develop and manage change; to integrate Quality Assurance Performance Improvement principles for service and organization work improvements.

10.    Ability to work with people of all social, economic, and cultural backgrounds; be flexible, open-minded and adaptable to change.

11.    Demonstrates the ability to connect patients and families with necessary services, both inside and outside the JFL network.

12.     Maintains a current working knowledge of services available in the local community, particularly services available to patients with limited or non-existent payment resources.

13.     Must demonstrate patience and tact when dealing with patients, families and other staff.

14.    Demonstrates commitment to the Partners-in-Caring process and the Behavioral Expectations in all interactions and in performing all job duties.

15.     Performs duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety, cost efficiency, and a commitment to the QAPI process.

Condition of Employment:

Employment in and by JFL is substantially different from working for and with other health systems and/or physician practices.  The Master Social Worker/ Social Worker I public behavior must be consistent with and supportive of JFL’s mission, vision, values, and Case Management Standards of Practice.  The incumbent has a significant responsibility for continually delivering and improving the company’s high quality, safe, satisfying, patient-family centered care. Employees may be directed to perform job-related tasks other than those specifically presented in this description.

 

Principal Accountabilities:

1.         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.

·         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, elderly abuse, institutional abuse and sexual assault.

·         Serves as a resource person and provides counseling and intervention related to treatment decisions and end-of-life issues.

·         Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the health care system.

·         Conducts Daily Rounding.

2.         Complex Discharge Planning

·         Identifies at an early stage of the hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate 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 care coordinators regarding the discharge planning status of all patients referred by them.

·         Assists Case Managers with discharge planning activities as requested.

·         Provides consultation to Case Managers when coordination with significant or intensive community resources is necessary to achieve desired treatment outcomes.

·         Receives referrals for complex patient problem resolution from Case Managers or care team members.

·         Provides information to the healthcare team, patient/family/caregiver regarding available resources and benefits for acute and post care services that ensures patient choice and a safe and timely transition.

·         Collaborates and coordinates with other members of the interdisciplinary team regarding timely and efficient ordering of consults, testing, and procedures in a manner which supports care delivery by actively intervening to resolve and escalate barriers to services by reporting to the Director of Case Management.

·         Collaborates and reviews with nurse case manager and other members of the interdisciplinary team to ensure the plan for the patient is clinically appropriate and matches the patient care needs and is consistent with available resources.

·         Screens and coordinates post-discharge needs for all high risk patients.

·         Referrals will be made to the Transfer Centers for determination of bed availability both in and out of local area. Informs Transfer Centers regarding trends and issues related to facility quality of care and changes to patient’s condition/prognosis.  When necessary, makes recommendations regarding facilities to be removed from the hospital’s referral list and advise physician/ interdisciplinary team on appropriate placement and facility that can meet patients needs based on medical necessity.

·         Validates discharge criteria for patient and families and notifies Case Managers of newly-identified resources or change in previously-identified resources.

·         Educates patient/family and physician regarding post-acute options and addresses issues of choice.

·         Facilitate patient care needs based on assessment and upon request by patient/ family representatives.

·         Uses quality screens to identify potential issues and forwards information to Director of Case Management.

·         Discharge planning evaluation will include an evaluation of the likelihood of post-discharge needs, capacity for self-care or the possibility for placement, anticipated discharge goals, who the plan of care was discussed with, and whether or not the plan of care was agreed upon by the patient/family representative.

·         Initial assessment of high-risk patient will be completed within 48 hours of the initial consult from nursing to avoid unnecessary delays in discharge.

·         Discuss and documents the results of the evaluation with the patient/family representative.

·         Completes discharge plans on patients that were not initially on admission.

·         Counsel patient and family members to prepare them for post- hospital care.

·         Reassesses patients discharge plan on an on-going basis for factors that may affect the appropriateness of the discharge plan.

·         Identify and  collaborate with the interdisciplinary team patients who are at risk for readmissions

·         Utilize teach-back method to assess the patient’s and caregiver’s understanding of the discharge plan.

3.             Utilization Review

·         Advocates for the patient while balancing the responsibility of stewardship for the organization and in general, the judicial management of resources.

·         Collaborates with nurse case managers on a daily basis to ensure patients are placed in the appropriate status.

·         Collaborates with the utilization reviewer/nurse case manager regarding medical necessity, continued stay reviews and authorization for post-acute care services.

·         Collaborates with Director of Case Management about the over/ under utilization of resources.

·         Educates physicians and members of the interdisciplinary team about preventing medical necessity denials and will escalate concerns to the Director of Case Management.

4.             Patient and Family Support in Legally Complex Cases

Initiates referrals in child abuse/neglect, domestic violence, guardianship (temporary/ permanent), foster care, adoption, mental health placement, advance directives, adult/elderly abuse, child protection and sexual assault.

5.             Actively participates in clinical performance improvement activities.

·         Assists in the collection and reporting of resource and financial indicators including case mix, LOS, cost per case, excess days, resource utilization, readmission rates, denials and appeals.

·         Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical and patient satisfaction data.

·         Collects, analyzes and addresses variances from the plan of care/care path with physician and/or other members of the healthcare team.  Uses concurrent variance data to drive practice changes and positively impact outcomes.

·         Collects delay and other data for specific performance and/or outcome indicators as determined by Director of Case Management.

·         Documents key clinical path variances and outcomes which relate to areas of direct responsibility (e.g., discharge planning).  Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrently

6.             Display a positive, professional image and attitude in all relationships with patients, families, peers and in the community at all times.

7.             Ensures safe care to patients by adhering to policies, procedures, regulatory standards and hospital case managers standards of practice, within budgetary specifications, including time management, supply management, productivity, and accuracy of practice.

8.             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; serves as preceptor, mentor, and resource to less experienced staff.

9.             Completes incident reports as required regarding discharge planning issues related to equipment and or foreseen unsafe discharges.

10.          Must display professionalism at all times by maintaining respectful relationships with coworkers, employers, and other professionals.

11.          Conduct and practice ethically, adhering to the tenets of the code of ethics that underlies his/her professional credential by adhering to the basic principles of ethics as outlined in the Case Management Standards of Practice.

12.          Off- Island Patient Transfers

·         Provide on-call coverage

·         Respond to initial call within 15 minutes

·         Report to hospital within 30 minutes

·         Coordinate safe and timely transfer of patients

·         Assists physicians and clinical team in coordinating transfer

·         Provides feedback to physician, nurse and patient/family representative regarding the status of patient transfer.

·         Acts as a liaison between the referring and receiving facility

·         Identifies and communicates delays/challenges in transfer process to the Director of Case Management and the Administrator on-call.

·         Notify Director of Case Management about emergency transfers (weekends and holidays) and daily during departmental meetings.

·         Provide the house supervisor with an update on the status of patient transfer before leaving institution.

·         Work collaboratively with physician and clinical staff to expedite the efficiency of patient transfers.

 

REQUIRED KNOWLEDGE/SKILLS/ABILITIES

1.     Knowledge of the policies, procedures, rules and regulations that apply to the practice of Social Worker I, in an inpatient care setting.

2.     Knowledge of hospital/departmental policies and procedures, emergency protocols, Joint Commission,   Center for Medicare and Medicaid services and all other local and federal regulatory standards

3.     Ability to make presentations before management, public groups, and staff.

4.       Knowledge of analytical and grammatical skills necessary to communicate effectively, verbally and in writing.

5.       Skilled in maintaining records and preparing reports.

6.       Ability to (or possess the skill level to gain ability to) define problems, collect data, establish facts, and draw valid conclusions.

7.       Familiarity with spreadsheet and overall computer skills.

8.       Ability to work with a wide variety of other professionals and staff engaged in the delivery of health care services.

9.       Ability to recognize and maintain confidentiality.

10.    Ability to gain the confidence and respect of the public to be served.

11.    Ability to work well independently including without administrative support when required.

12.    Organizational, multi-tasking, and time management skills are essential.

13.    Ability to work in a highly visible position undergoing significant changes with multiple constituents, each with demands exceeding resources.

14.    Ability to work independently, as part of a team and be available for on-call basis.

15.    Ability to display time management skills.