Care Coordinator / Acute Social Worker II - PRN Pool - Bayfront Hospital - St Petersburg

Orlando Health•St. Petersburg, FL

1d•Onsite

About The Position

This position collaborates with the assigned clinical team to identify patients who would benefit from care coordination services. This includes assessing patients' risk factors and their need for care coordination, clinical utilization management, and preventative care services. The role takes the lead in ensuring continuity and consistency of care across the continuum (inpatient, emergency, and ambulatory care/outpatient) to ensure integrated delivery across all settings. This includes facilitating comprehensive discharge planning in the hospital and follow-up care as an outpatient. The Care Coordinator develops an effective working relationship with Patient and Family Counselors/Social Workers and UR nurses to engage the patient/family in collaboration, advocacy, and problem-solving to support and enhance their functional ability, while ensuring an appropriate and timely discharge plan. Daily monitoring of progress towards discharge plans and/or the need to alter the discharge plan due to changes in patient condition/family needs is prioritized for patients at highest risk for complications, admission, or readmission. The role educates patients/families with chronic illnesses about evidence-based standards of care, including self-management strategies, and identifies support needs, developing action plans and providing creative guidance. Patients and families are educated about the healthcare system, and relationships between various settings are facilitated. Access to prescriptions, durable medical equipment (DME), and other identified services is ensured. The position contributes to team problem-solving through communication, collaboration, data collection, consensus building, and evaluating treatment option outcomes, including tracking patient progress towards care plan goals and revising the care plan as indicated. Advocacy for patients is provided to optimize their healthcare needs, including safety, physical, legal, and financial well-being. Referrals are made for education regarding healthcare delivery and reimbursement systems, prescription drug programs, health & wellness programs, community agencies, public and private organizations, housing options, and other services as appropriate. The role works with available IT resources (i.e., Phytel, Crimson) to facilitate registry reporting and maintenance of specified patient populations to improve disease outcome measures through evidence-based guidelines and the implementation of clinical decision support tools, referral and test tracking, and preventive medicine reminders. Participation in clinical outcome measurement, including identifying strategies that promote population health, is expected. Patient safety is ensured in job functions, including the implementation of policies, procedures, and standards. Regular and punctual attendance is maintained consistent with Orlando Health policies, the ADA, FMLA, and other relevant standards. Compliance with all Orlando Health policies and procedures is required. Clinical treatment interventions are provided under the supervision of licensed Mental Health Therapists, including facilitating patients' psychosocial adjustment along the continuum of care and transition to the next level of care. Psychosocial support groups are facilitated, and mental health education, information consultation, and support for patient and family needs are provided. Excellent analytical and team-building skills, along with the ability to prioritize and work independently, are essential. Knowledge and skills necessary to provide age-appropriate care are demonstrated, along with awareness of medical/legal issues, patient rights, and compliance with regulatory and accrediting agency standards. Other duties as assigned or required.

Requirements

Master’s degree from an accredited school of Social Work, Mental Health, Psychology or Marriage and Family Therapy is required.
Two (2) years of direct clinical experience with an emphasis on the population to be served in the assigned area.
Successful completion of Master’s level internship within the population to be served may substitute the two (2) years of experience.
Handle with Care (HWC) Certification required for Behavioral Health Unit.

Responsibilities

Takes the lead in ensuring the continuity and consistency of care, across the continuum (inpatient, emergency and ambulatory care/ outpatient) to ensure integrated delivery across all settings to include the facilitation comprehensive discharge planning (in the hospital) and follow-up care (as an outpatient).
Develops an effective working relationship with the Patient and Family Counselors/ Social Workers and the UR nurses to engage the patient/family to collaborate, advocate and problem solve, to support and enhance their functional ability, while ensuring an appropriate and timely discharge plan.
Daily monitoring of progress towards discharge plans and/ or need to alter discharge plan due to change in patient condition / family needs with a priority placed on those patients at highest risk for complication/ admission/ readmission.
Educates patients/ families with chronic illness about evidence-based standards of care to include self-management strategies.
Identifies support needs for patients and their families, develops action plan(s), and provides creative guidance in initiating and overcoming any self-management strategies.
Educates patients and families about the health care system and facilitates relationship building between the various settings.
Ensures patients have access to prescriptions, durable medical equipment (DME), and other services as identified.
Contributes to problem solving within the team through communication, collaboration, data collection, obtaining consensus and evaluating outcomes of treatment options to include tracking patient progress towards care plan goals and revising the care plan as indicated.
Advocates for patients in order to optimize their health care needs including but not limited to: safety, physical, legal and financial well-being.
Refers patients to education regarding the healthcare delivery and reimbursement systems, prescription drug programs, health & wellness programs, community agencies, public and private organizations, housing options, and other services, as appropriate.
Works with available IT resources (i.e. Phytel, Crimson) to facilitate registry reporting and maintenance of specified patient populations to improve disease outcome measures through evidence-based guidelines and the implementation of clinical decision support tools, referral and test tracking, and preventive medicine reminders.
Participates in clinical outcome measurement to include the identification of strategies that promote population health.
Ensures patient safety in the performance of job functions to include the implementation of policies, procedures and standards to support the assigned duties.
Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards.
Maintains compliance with all Orlando Health policies and procedures.
Provides clinical treatment interventions under the supervision of licensed Mental Health Therapist, to include facilitating patient’s psychosocial adjustment along the continuum of care and transition to next level of care.
Participates in facilitation of psychosocial support groups.
Provides mental health education, information consultation and supporting patient and family needs.
Possesses excellent analytical and team building skills, as well as the ability to prioritize and work independently.
Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served though knowledge of the principles of growth and development over the life span.
Demonstrates awareness of medical/ legal issues, patient rights and compliance with standards of regulatory and accrediting agencies.
Performs other duties as assigned or required.