Master Social Worker - MSW

Fresenius Medical Care•Espanola, NM

1d•Onsite

About The Position

The Master Social Worker provides psychosocial services to patients treated by the facility, including in-center and home dialysis patients (if applicable), utilizing Social Work Theory of Human Behavior and accepted methods of social work practice. This role involves working with the health care team to promote positive adjustment, rehabilitation, and improved quality of life for patients. In collaboration with the interdisciplinary team, the social worker informs, educates, and supports staff in understanding the emotional, psychological, and behavioral impact of Chronic Kidney Disease on the patient and family to ensure comprehensive quality care. The position supports the FMCNA commitment to Quality Indicators and Outcomes and Quality Assessment and Improvement (QAI) Activities, including those related to patient satisfaction and quality of life, and actively participates in process improvement activities to help patients achieve FMCNA Quality Goals.

Requirements

Masters in Social Work
Must have state required license
2 – 5 years’ related experience

Responsibilities

Assess patients' psychosocial status, strengths, and areas of need that may affect rehabilitation and optimal treatment outcomes as part of the comprehensive patient assessment.
Participate in care planning in collaboration with the patient and healthcare team to identify effective interventions that will help the patient meet rehabilitation, treatment goals, and improve quality of life.
Utilize FKC patient education programs, established social work theory and methods, social work focused interventions, and quality of life measurement instruments as part of assessment and care planning to address barriers and meet patient treatment goals.
Provide monitoring and interventions for the patient to adjust to dialysis and achieve optimal psychosocial status and quality of life.
Provide supportive counseling services to patients as permitted within the scope of their clinical training and state license.
Provide educational and goal directed counseling to patients who are seeking transplant.
Provide information and assist the team and patient with referral to community resources (home health services, vocational rehabilitation, etc.) to facilitate optimal treatment outcomes.
Maintain current knowledge regarding local vocational/educational rehabilitation programs and assist patients with referral and access to vocational rehabilitation to enable them to remain employed, become employed or receive education.
Assess patient awareness of advance directives; assist with accessing advance directive forms/information and facilitate discussion of advance directive wishes, if necessary, with the healthcare team and the patient's family/support persons.
In collaboration with the physician and nurse, participate in the discussion of patient DNR status in the facility to ensure patient and/or family understand and make an informed decision about their care.
Adhere to FMCNA Social Work Policy and Measuring Patient Physical and Mental Function Policy, including documentation.
Document based on MSW interaction and interventions provided to patient and/or family.
Provide psychosocial support and/or Social Work Focused Interventions to address non-adherence, quality outcome, and quality of life concerns for all patients based on acuity level.
Participate in monthly Quality review meetings with the interdisciplinary team.
Report on quality indicators related to adherence, such as Missed and Shortened Treatments, Quality of Life Trends, and Service Recovery.
Assess patient knowledge of kidney disease for barriers that may affect adherence to treatment.
Work with patient, family and health care team to provide education tailored to the patient’s learning style, communication barriers, and needs.
With other members of the interdisciplinary team, provide appropriate information about all treatment modalities.
Facilitate the transplant referral process and collaborate with interdisciplinary team on transplant waitlist management.
Provide ongoing education to patient/family regarding psychosocial issues related to End Stage Renal Disease (ESRD) and all support services that are available.
Review patient rights and responsibilities, grievance information (company and network) and other facilities policies with patient and/or the patients’ representative to ensure patients’ understanding of the rights and expectations of them.
Collaborate with the team on appropriate QAI activities.
Review Patient Rights and Responsibilities, Grievance Procedure & Important Numbers Handout, FKC Non-discrimination policy, DNR Statement (if applicable) and address any immediate needs/concerns.
Understand the referral and admission process and support the clinic in regard to the patient needs for scheduling to maximize adherence and adjustment.
Interview the patient to identify root causes or concerns for the discharge request (i.e. transfer to hospice, relocation, dissatisfaction with services or staff) and share causes/concerns with operational leadership.
Collaborate and function as a liaison for patient with Insurance Coordinators to address issues related to insurance.
In collaboration with Insurance Coordinators, provide information and education to patients about payment to dialysis (federal, state, commercial insurance, state renal programs, AKF HIPP, and entitlement programs).
Collaborate with the Insurance Coordinator of any changes to patient state that impacts insurance i.e. transplantation, discharged, loss of coverage, or extended travel.
Refer patients to patient billing solutions (PBS) department for questions/concerns in regard to treatment related bills.
Assist with interview process and decision to hire new personnel if requested by SW Manager/Senior Manager.
Work with the administrative support staff to maintain updated patient resource lists (e.g. maintain updated list of transportation resources).
Provide training to staff pertaining to psychosocial topics as needed.
Contribute and participate with weekly team huddles.
Discuss any urgent patient issues with staff.
Adhere to work defined caseload guidelines based on state regulatory requirements.
Perform other related duties as assigned.