Purpose and Scope

Our social worker provides psychosocial services to patients treated by our facility, including in-center and home dialysis patients. They work with the healthcare team to promote positive adjustment, rehabilitation, and improved quality of life for our patients.

Key Responsibilities

• Patient Assessment, Care Planning, and Counseling
• Assess patients' psychosocial status, strengths, and areas of need that may affect rehabilitation and optimal treatment outcomes.
• Participate in care planning with the patient and healthcare team to identify effective interventions that will help the patient meet rehabilitation, treatment goals, and improve quality of life.
• Provide monitoring and interventions for the patient to adjust to dialysis and achieve optimal psychosocial status and quality of life.
• Offer supportive counseling services to patients as permitted within the scope of their clinical training and state license.
• Provide educational and goal-directed counseling to patients who are seeking transplant.
• Assist the team and patient with referral to community resources to facilitate optimal treatment outcomes.
• Maintain current knowledge regarding local vocational/educational rehabilitation programs and assist patients with referral and access to vocational rehabilitation.
• Assess patient awareness of advance directives; assist with accessing advance directive forms/information and facilitate discussion of advance directive wishes, if necessary.
• Quality
• Provide psychosocial support and/or Social Work Focused Interventions to address non-adherence, quality outcome, and quality of life concerns for all patients based on acuity level.
• Participate in monthly Quality review meetings with the interdisciplinary team and report on quality indicators related to adherence.
• Patient Education
• Assess patient knowledge of kidney disease for barriers that may affect adherence to treatment.
• Work with the patient, family, and healthcare team to provide education tailored to the patient's learning style, communication barriers, and needs.
• Collaborate with the interdisciplinary team on transplant waitlist management and provide ongoing education to patient/family regarding psychosocial issues related to End Stage Renal Disease (ESRD).
• Review patient rights and responsibilities, grievance information, and other facilities policies with patient and/or patient representative to ensure patient understanding.
• Patient Admission and Continuity of Care
• Review Patient Rights and Responsibilities, Grievance Procedure & Important Numbers Handout, FKC Non-discrimination policy, DNR Statement (if applicable), and address any immediate needs/concerns.
• Understand the referral and admission process and support the clinic in regard to patient needs for scheduling to maximize adherence and adjustment.
• The Social Worker will interview the patient to identify root causes or concerns for the discharge request and share causes/concerns with operational leadership.
• Insurance and Financial Assistance
• Collaborate and function as a liaison for patient with Insurance Coordinators to address issues related to insurance.
• Provide information and education to patients about payment to dialysis, federal, state, commercial insurance, state renal programs, AKF HIPP, and entitlement programs.
• Collaborate with the Insurance Coordinator of any changes to patient state that impacts insurance.
• Staff Related
• Assist with interview process and decision to hire new personnel if requested by SW Manager/Senior Manager.
• Work with the administrative support staff to maintain updated patient resource lists.
• Provide training to staff pertaining to psychosocial topics as needed.
• Contribute and participate with weekly team huddles.
• Adhere to work-defined caseload guidelines based on state regulatory requirements.

Physical Demands and Working Conditions

Travel required (if multiple facilities or home visits, if applicable).

Supervision

None.

Education and Required Credentials

• Masters in Social Work
• Must have state-required license
• Meets the applicable scope of practice board and licensure requirements in effect in the State in which they are employed.

Experience and Skills

• 0-2 years related experience