The position involves providing discharge planning for patients to ensure continuity of care and facilitate discharge to the least restrictive setting. The role requires identifying 'high risk' patients to provide necessary social work services and complex discharge planning. The social worker will interview patients, families, and community support services to assess psychological, social, environmental, and financial statuses, addressing identified needs. Participation in Interdisciplinary Discharge Planning Rounds is essential to assess needs, identify problems, and communicate ongoing interventions. The social worker will engage patients and families in decision-making during hospitalization, particularly regarding discharge planning and treatment decisions. Crisis intervention services will be provided to help patients and families cope with end-of-life issues, chronic illnesses, and catastrophic events. Education about discharge planning and available programs/services will be a key responsibility, along with negotiating and coordinating community-based services to ensure continuity of care. The social worker will document all assessments and interventions in the Medical Record to enhance communication and meet regulatory standards. Monitoring discharge planning delays and attending relevant conferences/workshops for continuing education are also part of the role.
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Education Level
Master's degree
Number of Employees
5,001-10,000 employees