The Social Worker creates optimal outcomes for the patient and family by managing complex psychosocial and economic co-morbidities. Through advanced practice skills, they mobilize resources to reduce risk and serve as an ambassador between the hospital and community. They provide social work services to patients and families to optimize their ability to benefit from treatment, cope with the realities of their medical condition, and participate in their care. This role coordinates transitions of care for patients with high psychosocial needs, develops and maintains current knowledge of and liaisons with local, state, and federal services, and supports the efforts of HIM and Patient Accounts by ensuring timely, accurate, and complete data entry in multiple information systems/data bases. The Social Worker ensures understanding through collaboration with the Care Manager and other interdisciplinary team members for review of the multidisciplinary plan of care, attends Multidisciplinary Rounds or Huddles, and reports on psychosocial status and its implication for transitions of care. They monitor progress toward the goals of the social work plan of care and revise it in response to changes in patient needs and condition. They assess any potential obstacles to successful reintegration into the community and escalate through appropriate channels to resolution. This role is responsible for performing job duties in accordance with the mission, vision, and values of Tampa General Hospital. They effectively communicate and collaborate with all members of the health care team to facilitate the episode of care so the patient receives services in a safe and timely manner, and the patient and family are provided all necessary resources and education. They interpret and communicate complex patient/family needs and role model caring practices to other caregivers. They assess patients' and families' psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness, and ability to cope. They counsel patients and families regarding emotional, social, and financial consequences of illness and/or disability, and access and mobilize family/community resources to meet identified needs. Social workers provide brief crisis counseling and therapeutic intervention with a particular focus on frequent utilizers of the healthcare system. Post-discharge follow-up phone calls are placed to high-needs utilizers of the ED in an effort to prevent readmission. Social workers see all patients for whom their team is consulted and round daily with the multidisciplinary team. They provide therapeutic intervention to facilitate complex discharge planning by completing psychosocial assessments and high-risk screens after independent case-finding or receiving referrals. Based on the assessment, they develop and document a short-term treatment plan. They identify the need for and conduct family meetings that result in comfort, decisions, and other important outcomes. They serve as the lead in obtaining charity and financial resources, legal guardianship, adoptions, psychiatric referrals, and competency determinations. They utilize effective principles of interviewing alleged victims, perpetrators, family members, and significant others. They provide intervention for end-of-life, guardianship (temporary/permanent), foster care, adoption, etc. They serve as the point person in child abuse/neglect, adult/elderly abuse/neglect, institutional abuse, and domestic violence. They serve as liaison between Tampa General and state and county child and adult protective teams. They provide intervention in guardianship (temporary/permanent), foster care, adoption, and mental health level II placements. They participate in Care Coordination Rounds and help create function and productivity on the many teams to which the SW belongs, facilitating the resolution of conflict in order to present a united message to patients and families. They lead or co-lead a standing support/education group for an at-risk population. They work with people and agencies in the community to improve responsiveness, capabilities, alignment, and evaluation of services to patients and families. They actively participate in clinical performance improvement activities and complete all processes required to facilitate patients' movement through levels of care. They provide specialized mental health services including, but not limited to, Crisis Intervention and Addiction Assessments and recommendations for psychiatric referral or community resources. They support those undergoing acute crisis which often results in the use of de-escalation techniques necessary to avoid episodes of physical violence.
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Job Type
Full-time
Career Level
Mid Level