Social Worker - Full Time - Days

Best Care•Council Bluffs, IA

22h•Onsite

About The Position

Social Work is a professional and academic discipline that seeks to improve the quality of life and subjective well-being of individuals, and communities. Properly identifies patient problems, needs and barriers to care and coordinates the selection of appropriate services.

Requirements

Bachelor's Degree in Social Work or Human Services related area required.
Minimum 1-2 years relevant discharge planning or counseling experience required.
Knowledge of the discharge planning process, community resources and the networking process necessary to provide high-quality service to patients and their family, hospital staff and others seeking services.
Knowledge of counseling techniques to the degree necessary to provide appropriate emotional support to patients, their families, hospital staff and the public, and the process of an interdisciplinary team approach to patient care.
Excellent communication skills, verbal and written.
Demonstrates ability to maintain favorable relationships with physicians and health system personnel.
Is self-directed and able to multi-task and prioritize work assignments.
Able to deal with resistance and complex situations.
Functions as an educator to physicians and health system personnel.
Must be objective and logical.
Demonstrates critical thinking skills.
Ability to foster an attitude of teamwork and trust.
Requires skills in obtaining empathetic listening, psycho-social assessment, problem solving and crisis intervention techniques, and facilitate an interactive team process in working with patients.
Requires the ability to compile information into an accurate objective social history, communicate effectively, and assess the need for follow-up of certain patient/family/employee situations.
Requires the ability to assess patient/family needs to provide for quality service delivery.

Nice To Haves

Master’s degree preferred.
Certified Social Worker (CSW) preferred.

Responsibilities

Complete psycho-social evaluation of the patient and family system.
Properly identifies patient's likelihood of needing post hospital services and availability of those services ensuring a smooth and safe transition at discharge.
Assists in the development of the discharge plan with patient/family and interdisciplinary team.
Provides complete functional, psychosocial assessment within 24 working hours of referral, order or identification of a patient.
Performs an ongoing assessment of the patient, support system, and environment to determine factors that impact the patient's ability to maintain the highest level of independence.
Ensures services provided are consistent with the patient's identified needs.
Facilitates discharge planning by documenting an accurate picture of patient's discharge needs, services offered and any barriers to discharge or plan of care from being implemented or carried out.
Transitioning of the patient to the appropriate level of care needed.
Provides assistance with discharge planning – identifies appropriate agencies/facilities for patients requiring assistance at home or placement at another level of care.
Maintains a level of expertise and current knowledge base on available community resources and services available.
Informs patient/family of services available and initiate services that are consistent with patient's identified needs to maintain the highest level of independence.
Documents and informs patient/family of their freedom to choose providers of post hospital care and respect preferences.
Documents and discusses the results of evaluation with patient/family.
Seeks input from other healthcare facilities and professionals who may provide care before admission.
Initiates services that are consistent with the patient's identified needs by providing referral to appropriate resources as soon as recognized.
Provides and documents a list of agencies available that serve the geographical area requested by the patient. (HHA, SNFs).
Discloses to patient/family if the hospital has any financial interest with post hospital agencies.
Effectively communicates with agencies/facilities of the patient needs.
Provides referral to appropriate community resources as soon as recognized to need identified patient's discharge and financial needs.
Provides appropriate information through Ensocare to agencies/facilities.
Keeps patient/family informed of anticipated discharge4 and changes in discharge plan.
Participate in the development of a discharge plan and assesses the effectiveness.
Collaborates with physician, interdisciplinary team and patient/family to develop comprehensive, proactive discharge plans for all complex patients.
Participates in daily huddles and unit rounds and effectively communicates any barriers to discharge with patient/family, physician and interdisciplinary team.
Collaborates with interdisciplinary team to ensure barriers are addressed and ensure a safe discharge occurs.
Initiates appropriate interventions to ensure the patient/family of a safe discharge.
Identification of financial needs that impact the patient's ability to meet their financial responsibility and initiates appropriate referral.
Identify and assist patient in obtaining necessary durable medical equipment to ensure a safe discharge.
Completes PASSR for nursing home admissions.
Performs mini mental exams as requested to assist appropriate safe discharge.
Ensure that proper committal procedure performed.
Assist physician and patients/families in advance directive and end of life discussions and assure that proper documentation obtained.
Initiate appropriate referral to assist with completing advance directives, guardianship, disability assistance etc.
Provides immediate counseling of patients and family and effectively diffuses crisis and refers to appropriate services for abuse/neglect as needed to include APS, CPS.
Assist physicians, patients and families with adoption process.
Assist physicians, patients and families with coordination of dialysis needs.
Promotes the education of all members of the interdisciplinary team, physicians/office staff, and patient/families.
Provides patient/family education and counseling about existing health problems and related care.
Promotes the education of all members of the interdisciplinary team, physicians and office staff, community providers and patient/families to Social Worker responsibilities.
Acting as resource to staff for counsel, education and referral for access to the most appropriate care.
Provides ongoing education based on needs assessment – including use and understanding of community resources, issues related to funding and areas of patient choices and accountability.
Communicates issues/trends (positive/negative) to Director/Supervisor.
Participates in new employee orientation.
Willingly performs other duties as assigned.
Participates in the development and implementation of community collaboration based on evidence-based practice that includes core values, readmission efforts, decreasing length of stay efforts, and improving communication with the community.
Assures that the core values, readmission, LOS, communication efforts are a community process and that the guidelines are well researched.
Knowledgeable of community care efforts to decrease readmissions, appropriate ED utilization and admissions.
Makes appropriate referrals to community providers through Tav Connect.
Coordinates community meetings to meet the needs of the community effort that benefit the patient and/or family through the episode of illness from pre-hospital to post-hospital care.
Utilizes Tav Connect to document community resources and barriers of high-risk patients.
Participates in Readmission and Chemo Huddles to ensure appropriate utilization of resources, appropriate setting for care and opportunities to decrease readmissions.
Provides concerns or barriers with community partners so communication will occur as soon as problems or concerns are identified.