Social Worker - Discharge Planning

Owensboro Health•Owensboro, KY

22h•Onsite

About The Position

Oversees care management and coordination of activities for patients of the healthcare system. Develops and monitors care management coordination processes and support of patients for multidisciplinary teams. Identifies high acuity patient population, high utilizers, and high readmission risk patients.

Requirements

Requires critical thinking skills and decisive judgment.
Works under general supervision.
Must be able to work in a stressful environment and take appropriate action.
Applies more advanced skills and knowledge in the area of specialization.
A minimum of 1 year relevant experience preferred
Bachelor's degree or higher in Social Work required upon hire
LSW - Licensed Social Worker in the State of Kentucky required upon hire OR LCSW - Licensed Clinical Social Worker in the State of Kentucky required upon hire OR CSW - Certified Social Worker in the State of Kentucky required upon hire

Responsibilities

Works with all clinical teams as a resource on care management of all patients of the healthcare system to ensure care completion in and out of the hospital setting.
Involves the patients in activities to improve their health (patient engagement); educates patients about self management tasks they can undertake to gain greater control of their health status.
Manages assigned panel of chronic care, high acuity, and readmission risk patients.
Develops relationship with patient as an integral member of the team.
Provides follow-up contact with patient as indicated to ensure compliance with recommendations, medications, lab, x-ray, specialist visits, Primary Care Physicians (PCP) visits, dietitians, and durable medical equipment (DME), etc.
Manages many aspects of the patient's care: referral to specialists, hospitalizations, emergency department (ED) visits, ancillary testing, nd other enabling services.
Available to provide telephone advice per protocol, handles urgent and emergent calls.
Anticipates the needs of this patient population seeing that necessary documentation and planning is completed for patient continuity of care.
Works with patient and patient's care team to coordinate change readiness, needs assessment, and develops an individualized treatment care plan.
Assists patient in setting SMART goals for self-management, teaches them how to do self-management tasks, and reports abnormal finding to their physician team.
Collaborates with the patient, physician, and other care team members in assessing the patient's progress toward health care goals.
Assesses barriers when patient has not met treatment goals, is not following treatment plan of care, or has not kept important appointments.
Oversees the development, procurement, and adoption of patient self-management educational resources used by the clinical teams.
Collaborates with payer care managers for additional services when appropriate.
Develops a list of medical supplies and community resources available to patients and maintains collegial relationships with the entities used most frequently.
Works with consulting physicians, hospitals, ED, and other frequently used healthcare sources to clarify roles and develop effective, efficient, and timely communication between PCPs and these entities.
Coordinates consults, referrals, hospital/ED, and community resource follow-up and tracking processes for the health system working to have clerical component done by appropriate clerical staff.
Develops workflows and protocols within the healthcare system that ensure the ED, hospital, and community resource follow-up.
Facilitates clinical follow-up with patients when indicated.
May make home/community visits when deemed applicable to assist with social determinants of care and resolution to social barriers.