The medical social worker is responsible for the implementation of standards of care for medical social work services. This role involves ongoing interdisciplinary assessment and development of individualized plans of care in partnership with the patient, their representative, and caregivers. The social worker assesses the psychosocial status of patients related to their illness and environment, communicating findings to the registered nurse. They carry out social evaluations, plan interventions, and provide patient, caregiver, and family counseling. Services are provided as ordered by the physician and indicated in the plan of care. The role requires communication with the physician and other healthcare practitioners regarding the home health plan of care, and assisting the team in understanding social and emotional factors related to health problems. The medical social worker prepares clinical notes, provides information and referral services for practical and environmental needs, and offers education to patients, families/caregivers, and community agencies. They serve as a liaison between patients/families/caregivers and community agencies, maintaining collaborative relationships with organization personnel to support patient care. Additionally, they maintain and develop contracts with public and private agencies, participate in the total plan of care and case conferences, and assist in discharge planning. The role may involve supervising Social Worker Assistants as directed and participating in the HHA's quality assessment and performance improvement program and HHA-sponsored in-service training. Other duties may be delegated by the Director of Nursing/Supervisor.
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Career Level
Mid Level