Medical Social Worker (BSW or MSW)

Sonoma Valley Hospital•Sonoma, CA

7d•$49 - $68

About The Position

Provides social services to patients with identified social, behavioral and/or mental-emotional needs in the inpatient and emergency department settings. Acts as a liaison with community provider agencies to develop care resource networks. Works with the multidisciplinary team to build effective care coordination planning for patients and their families with a focus on holistic care. Demonstrates a strong understanding of the physical, emotional, and social challenges associated with aging, including chronic illness, cognitive decline, and grief. Must respect the autonomy and dignity of older adults, ensuring they have a voice in their care decisions. Provides support to caregivers in managing the stress and demands of caring for an aging loved one, with a focus on preventing caregiver burnout. Assists patients and families with discharge planning, including identifying appropriate post-hospital care settings (e.g., home, rehabilitation, or long-term care) and connecting them with necessary resources.

Requirements

Bachelor's degree in Social Work from an accrediated university
Minimum 2 years' of social services experience in the fields of aging, health, or long-term care.
Excellent written and verbal communication skills.
Ability to manage priorities and workflow.
Versatility, flexibility, and a willingness to work within constantly changing priorities with enthusiasm.
Ability to deal effectively with a diversity of individuals at all organizational levels.
Good judgement with the ability to make timely and sound decisions.
Proficiency with computers and Microsoft Excel.

Nice To Haves

Master's degree preferred.
California Licensed Clinical Social Worker (LCSW) preferred.
Previous experience with Sonoma County provider agencies & care coordination is preferred.

Responsibilities

Completes assessment and coordinates discharge planning for patients with social/ behavioral/mental- emotional needs, (including dementia, depression, etc) and functional abilities.
Coordinates placement referrals for boarders, the homeless, and the under or uninsured and those with behavioral health needs, including substance abuse.
Coordinates the homeless discharge planning process, ensuring that the organization is in compliance with all requirements.
Ensures departments have the resource tools to comply when social work or case management are not present.
Maintains the homeless log and the clothing closet.
Serves as an advocate for patients' rights, needs, and preferences within the healthcare system, ensuring they receive appropriate and respectful care.
Provides crisis intervention to patients and their families in the acute and emergency setting with compassion, support and guidance, helping them manage the stress and challenges of caring for an aging loved one and those with mental health challenges.
Connects patients and families with community resources, including financial assistance, social services, and support groups.
Assist patients and families with long-term care planning, including identifying appropriate care settings and financial resources
Builds community provider partnerships including clinics, first responders, non-profits, and county services to effectively address social needs as they present in our patient population.
Participates in Emergency Department rounding and daily inpatient morning huddles.
Works in collaboration with members of the multidisciplinary team to develop and implement individualized care plans.
Assists with post discharge follow-up on high risk patients to promote primary care engagement, confirm that services are in place, and help prevent readmission.
Provides followup for patients who are frequent users of the emergency department, as needed.
Maintains accurate and up-to-date records of client progress and interventions in compliance with regulatory and ethical standards.