Summary

SUMMARY: Restores patients to optimum health and social adjustment, while facilitating a positive impact on the hospital transition of care; informs the health care team of the patient's social, emotional, environmental, and financial needs and resources that may influence their treatment options and discharge plan; assists case manager nurses with complex social situations and discharge planning.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

1. Collaborates with Care Transition team and Health Advocates for high risk patients for timely follow-up appointments and confirms prior to discharge that complex patients are appropriately linked to community services.

2. Coordinates patient care activities with other members of the healthcare team, the patient, the patient's representatives, and community partners and makes referrals as appropriate.

3. Effectively intervenes in suspected abuse/neglect cases and in complex or high risk situations as requested; is competent to identify and intervene with high risk behaviors, responding to traumas.

4. Identifies and mobilizes patients and family strengths to optimize use of healthcare and community resources; in coordination with patient and family wishes, guide/assist in securing needed post discharge services which may require negotiating for services covered but not readily available; provides consultation and education to team members regarding patient/family (psychosocial and discharge planning) issues and community resources.

5. Identifies potential problems prevents and or resolves variances to the care management plan; assesses and coordinates family and community resources to meet identified needs to support the discharge plan.

6. Intervene with patients and patient's representatives regarding emotional, behavioral, and financial barriers to current illness and/or disability.

7. Leads patient centered conferences to meet needs and desires of the patients.

8. Maintains patient records including patient assessments, plans interventions, patient/family involvement, outside agency communications and interdisciplinary contacts.

9. Participates in discharge planning activities; effectively identifies and intervenes with high risk discharge planning issues with psychosocial complexity; whether referred by other healthcare providers or identified through assessment. Assists Care Management Nurse with discharge planning efforts as requested; obtains or coordinates referrals for post-discharge service needs, if required; mobilize resources to affect rapid and timely movement of the patient through system to achieve targeted discharge times established by AHS.

10. Performs psychosocial assessment interview with patients and/or families and records this assessment in the patient's medical record. Assesses patient's level of functioning, environment, appropriateness and adequacy of support system related to illness and ability to cope; reassesses the patient's condition when changes occur and revises the care plan when appropriate. Performs rapid assessments and developing crisis management plans for referral, evaluation and admission.

11. Provides patient advocacy including primary responsibility for initiating processes regarding capacity determinations, grief counseling, and conservatorship/guardianship; takes advocacy leadership role regarding adoption/surrogacy cases.

12. Refers and assists patients/families in applying for appropriate financial programs (CCS, SDI, SSI, SSD, private pensions) and legal instruments as needed.

13. Screen for any barriers to care such as substance abuse, neglect, financial limitations or housing.

14. Serves a resource and provides counseling and treatment related to palliative care or end of life planning.

15. Provides crisis intervention, bedside counseling and resources/referrals for mental health care.

MINIMUM QUALIFICATIONS:

Required Education: Master's degree in social work/welfare issued by a school accredited by the Counsel of Social Work Education.

Required Experience: Two years of post-graduate Social work or Case Management experience in a medical setting or community agency. One year of social work internship in an acute care hospital may be considered.

Preferred Experience: 2 years acute care hospital setting

Preferred Licenses/Certifications: Active certification in Case Management (ACM or CCMC), Current and valid license as a Clinical Social Worker issued by the State of California Board of Behavior Science Examiners. Bilingual preferred.