Create optimal outcomes for the patient and family by managing complex psychosocial and economic co-morbidities. Through advanced practice skills, mobilizes resources to reduce risk, and serves as ambassador between hospital and community. • Works with the Case Manager and the treatment team to develop a safe and timely Discharge Plan A and B that complies with regulations and laws regarding patient and family wishes • Identifies the need for and conducts family meetings that result in comfort, decisions, and other important outcomes • Serves as the lead in obtaining charity and financial resources, legal guardianship, adoptions, psychiatric referrals, and competency determinations. • Leads or co-leads Care Coordination Rounds • Help create function and productivity on the many teams to which the SW belongs, facilitating the resolution of conflict to present a united message to patients and families • Acknowledge issues of diversity and adjust practice accordingly • Works with people and agencies in the community to improve responsiveness, capabilities, alignment, and evaluation of services to patients and families • Collaborate with Risk Management, Patient Relations, Utilization Management, and Quality Management about potential problems and preclude outcomes detrimental to AMC • Base individual practice patterns on a sound knowledge base of social work principles and methodologies, social work policies, and the NASW Code of Ethics • Demonstrate flexibility in providing department coverage as needed, including possible modification of role, responsibilities, and assigned caseload • Completes initial screen of patients and families and a comprehensive psychosocial assessment of patients • Assists patients and families in understanding their illness and treatments options, as well as consequences to various treatments or refusal of treatment • Assists patients and families in communicating with treatment team • Provides crisis intervention • Advocates for patient care and timely discharge plan • Coordinates patient discharge and continuity of care planning • Educates hospital staff on patient psychosocial needs • Educates patients and families on levels of care; acute, sub-acute, community services and resources
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Job Type
Part-time
Career Level
Mid Level
Number of Employees
5,001-10,000 employees