PHO Case Manager Social Worker

Cape Cod Healthcare Inc. • Plymouth, MA

25d

About The Position

1. Patient enrollment into case management: assists case managers and clinical pharmacist(s) in enrolling identified patients for case management, including conducting patient outreach, patient enrollment, patient follow-up and referral to non-behavioral health case managers as appropriate. Enrolls behavioral health patients into behavioral health case management, including enrolling identified patients for case management, including conducting patient outreach, patient enrollment and patient follow-up until discharge. 2. Assists patients and families to adjust to illness and lifestyle changes related to illness and hospitalization. a. Remains available to patients, family and staff through an open referral system. b. Interviews patient and family members to obtain information about home environment, family relationships, health history, and patient's personality traits. c. Assists patients and families to understand, accept, and follow medical recommendations. 3. Assists patients and families to adjust to illness and lifestyle changes related to illness and hospitalization. a. Remains available to patients, family and staff through an open referral system. b. Interviews patient and family members to obtain information about home environment, family relationships, health history, and patient's personality traits. c. Assists patients and families to understand, accept, and follow medical recommendations. 4. Assists in patient care planning to ensure continuation of treatment in an atmosphere conducive to preservation of health. a. Evaluates the ongoing medical and psychosocial needs for care planning in order to set up appropriate community services. b. Evaluates data gathered in terms of the medical plan of treatment, available social service programs and plans a pertinent psychosocial treatment program that will provide maximum benefit for each patient. c. Assists patient/family in the procurement of essential equipment to allow optimum and safe function at home. d. Assists patient/family in the decision making process leading to the selection of and placement in an appropriate long term and short term facility. 5. Provides information and referral for continuing care and crisis intervention. a. Brings voluntary community bases services into play as appropriate to patient and family needs. b. Utilizes resources to assist patient to resume life in the community or to learn to live with disability. c. Functions as a liaison on behalf of patients with appropriate community agencies. d. Evaluates the appropriateness of community services as possible and develops plans to meet patient needs. e. Maintains excellent relationships with community agencies. 6. Works cooperatively with co-workers and communicates effectively with departmental staff; other departmental personnel and health care facilities; physicians, patients and visitors. a. Participate in team-based huddles with physician practices, including monthly onsite visits b. Acts in accordance with professional ethics and within departmental policy and procedure. c. Functions within the professional Social Work Code of Ethics. d. Is available to all clinical areas for social work services as needed and assigned. e. Prepares and updates records for each patient, documenting as per policy. f. Maintains monthly statistical data. g. Observes all safety, infection and environmental control procedures. h. Functions in such a way as to meet departmental quality assurance program. i. Assists in care and maintenance of department equipment and supplies. j. Attends and actively participates in meetings and serves on committees as requested. 7. Performs other work related duties as requested/directed. 8. Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers.

Requirements

• MSW or related discipline and state licensure in related mental health field
• Completion of an approved de-escalation Certification Course within 90 days from hire (course offered within)
• Familiarity with community resources and ability to access same.
• Knowledge and experience in use of the DSM V with regard to psychiatric diagnoses.
• Ability to maintain effective working relationships with patients, medical staff and the public.
• Ability to communicate clearly and effectively in person, in writing, or by phone.
• Skill in appropriate assessment, examination, treatment techniques.
• Skill in QM, medication, infection control, safety and confidentiality policies by effectively role modeling appropriate behavior.
• Skill in leadership and mentoring.

Responsibilities

• Patient enrollment into case management
• Assists patients and families to adjust to illness and lifestyle changes related to illness and hospitalization
• Assists in patient care planning to ensure continuation of treatment in an atmosphere conducive to preservation of health
• Provides information and referral for continuing care and crisis intervention
• Works cooperatively with co-workers and communicates effectively with departmental staff; other departmental personnel and health care facilities; physicians, patients and visitors
• Performs other work related duties as requested/directed
• Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Hospitals
• Number of Employees: 5,001-10,000 employees