The Social Worker, BSW utilizes principles of care coordination to support patients, families, and caregivers to ensure a successful discharge plan. The Social Worker organizes, directs, and coordinates the care across the continuum in collaboration with the RN Case Manager. The Social Worker collaborates with the interdisciplinary team of providers, nurses, health plans, RN case managers, and external providers while advocating for the patient to appropriately coordinate the care continuum, and formulate a safe effective discharge plan. The Social Worker assumes a leadership role within the health care team by attending structured interdisciplinary bedside rounds (SIBR) on assigned units. Work may involve in-depth assessment of family dynamics and needs which requires comprehensive working knowledge of community resources to direct positive discharge outcomes while focusing on social determinants of health that impact a patient’s overall well being

Essential Job Functions

• Assesses, plans, implements, coordinates, monitors, and evaluates options for patients, their families, caregivers and the health care team, including providers, to promote effective care coordination outcomes.
• Completes patient assessments to identify barriers to discharge with a focus on social determinants of health, patient’s ability for self-care, or any potential post-hospital services that may be required at discharge.
• Identifies any psychosocial, clinical, cultural, spiritual, or financial barriers that may impede a safe effective transition from the hospital.
• Manages transitions of care effectively as one of the critical components to reducing readmissions and poor health outcomes.
• Initiates care coordination strategies that are evidence-based and outcome focused.
• Collaborates with the multidisciplinary team to formulate a safe discharge team.
• Utilizes the readmission risk tool to identify barriers to effective discharge plan.
• Identifies patient care requirements by establishing personal rapport with patients, families, and caregivers.
• Establishes a compassionate environment by providing emotional, psychological, and spiritual support to patients and families.
• Ensures safe and effective transitions of care that help to promote positive health care outcomes while focusing on social determinants of health that affect a patient’s overall well-being.
• Promotes patient's independence by working to transition to the least restrictive level of care and establishing goals of care with patient, family, and caregiver.
• Has knowledge of resources in the area such as post-acute providers, home health agencies, hospice, LTACH, IP rehab, assisted living, skilled nursing facilities, DME, etc.
• Arranges for post-hospital services prior to discharge and ensures they are done timely to avoid delays in discharge. Acts as the liaison between the patient, hospital, and post-hospital services.
• Maintains a safe and clean working environment by complying with environmental procedures, rules and regulations.
• Demonstrates competencies of critical-thinking skills for transitioning complex and high-risk patients while simultaneously assuming the patient advocate role to ensure conflict-free, unbiased and culturally sensitive discharge planning.
• Maintains professional knowledge by attending education workshops; reviewing professional publications; establishing personal networks; participating in professional societies.
• Protects patients and employees by adhering to infection-control policies and protocols
• Assures care coordination that takes into account patients' values, needs, preferences and their choice to self-direct care.
• Maintains patient confidence and protects operations by keeping information confidential and abiding by HIPPA standards.
• Puts the patient at the center of all care decisions and is an essential driver to ensuring that patients get the right care, in the right setting, at the right time.
• Effectively manages transitions involving comprehensive planning, targeted outreach and the timely transfer of information between parties critical to the transition. Manages transitions of care effectively as one of the critical components to reducing readmissions and poor health outcomes.
• Facilitates the flow of care to expedite an appropriate discharge and prevent readmissions.
• Maintains a cooperative relationship among health care teams by communicating information; responding to requests; building rapport; participating in team continuous quality improvement and problem-solving methods.
• Ensures complete, accurate, timely and appropriate documentation of patient assessment, and any information for the discharge plan.
• Communicates discharge plan to members of the health care team via attendance at SIBR rounds, concurrent documentation, and verbal communication.
• Evaluates and projects discharge planning needs and coordinates post-acute care needs of patient in assigned case load.
• Coordinates post-hospital needs in a timely and effective manner.
• Applies advanced interpersonal skills in negotiating appropriate plan of care needs for assigned patient population.
• Acts as a resource/consultant to internal customers for extensive knowledge of community resources and expertise in accessing social/community systems.
• Reviews the laws and regulations that influence the practice of social work. Has working knowledge of Advanced Directives, HIPAA, and health care proxy formats.
• Works with legal team for potential guardianship or adoption cases.
• Other duties as assigned

Required Qualifications

• Bachelor’s Degree in Social Work.
• Strong leadership ability, good organizational skills, independent and critical thinking skills, sound judgment, and knowledge of legal aspects.
• Strong ability to communicate complex and/or controversial topics and concepts to a wide and diverse audience.

• Knowledge of Payor/Insurance Benefits
• Functional Skills on PC and Related Software (Microsoft Office)
• Knowledge of basic Office Equipment such as copier, fax machine, etc.

Preferred Qualifications

• Experience in Acute Healthcare

License, Certification & Clearances

• Act 33 with renewal
• Act 34 with renewal
• Act 73 FBI Clearance with Renewal
• LBSW preferred
• Case Management Certification preferred

Supervisory Responsibilities

• This position has no direct supervisory responsibilities, but does serve as a coach and mentor for other positions in the department.

Position Type/Expected Hours of Work

• Incumbent will be scheduled based on operational need (rotate shifts, weekends, holidays, standby, on-call, etc.).
• Travel may be expected locally between Excela Health locations.

LEAN

• Actively promotes a Lean work culture by performing team member duties to encourage consistent use of LEAN principles and processes, including continually seeking work process improvements. Recognizes the necessity of taking ownership of one’s own motivation, morale, performance and professional development. Strives for behavior consistent with being committed to Excela’s missions, vision and values.

AAP/EEO

• Excela Health is an Equal Opportunity Employer. It is the policy of Excela Health to prohibit discrimination of any type and to afford equal employment opportunities to employees and applicants, without regard to race, color, religion, sex, national origin, age, marital status, non-job related disability, veteran status, or genetic information, or any other protected class. Excela Health will conform to the spirit as well as the letter of all applicable laws and regulations.
• Ability to perform the Essential Functions listed on the Physical Conditions and ability to perform the Essential Functions on the Working Condition chart below.

Work Environment

Effective March 2020 or during pandemic: goggles, face shield and mask are required according to CDC guidelines

Physical Demands

When lift requirement is in excess of 50#, lift assistance (2 person) and/or transfer device is required.

Education

• Bachelors or better in SOCIAL WORK

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)