SOCIAL WORKER

The purpose of the Social Services Department is to provide services to patients and their families in order to promote optimal functioning, and to enable patients to utilize health care to achieve their optimal level of health. Social work recognizes the relationships of psychosocial factors to illness as having influence on the patients' recovery. Through direct services to patients and families, and through collaboration and consultation with the physician and other personnel, social work can aid the patient to utilize health care services and his own resources in maximizing well being.

General Duties

• Assist the patient and family with social, emotional and family problems precipitated by illness and hospitalization.
• Encourage optimum utilization of health care and resources.
• Serve as liaison between the Hospital, Long Term Care Facilities, Alternative Care Facilities and other resources in the community.
• Develop a discharge plan of care with the patient and family/responsible party.

Functions and Areas of Responsibility

• Maintain goals on patient care plan and update as needed.
• Discusses Advance Directives; assists obtaining copies for facility and/or in facilitating one; evaluates if Advance Directives need to be reviewed due to a change in status; and assists with monitoring for presence of Advance Directives in chart.
• Identifies psychosocial needs and preferences, customary routines, concerns and choices.
• Complete a social history, Social Service Assessment
• Provide supervision to social work interns.
• Assist patients as needed with financial and legal matters
• Provide support and guidance on a continuing basis to patients and families as needed
• Serves as an advocate for patients and assists with problems referred to Social Services by other departments.
• Coordinates supportive care for terminal patients.
• Keeps abreast of local, state and federal regulations and current legislation, trends and resources as they pertain to Social Services in health care settings.
• Plans and implements C.Q.I. plan for department.
• Facilitate and help guide interdisciplinary care rounds Monday-Friday

Care Navigator

• Collaborates with the health care team and community care providers to ensure that an effective and timely transition in level of care is implemented upon discharge.
• Provides medical and pre-op/postop surgical patients with education, advocacy, and decision making support related to the impact of medical illness, social/functional/financial needs on healing, recovery, chronic care, or end of life care.
• Engage patients as active participants in the planning of their recovery process, elevate the information from and access to their providers, and empower patients toward long-term health and wellness upon discharge.

Discharge Planning

• Check discharge needs/assessment in patients' chart for data. Identify patients who need discharge planning.
• Arrange for a multidisciplinary care conference as needed.
• Arrange for alternative living arrangements if needed.
• Arrange for services and/or equipment if needed.
• Communicate and work with nursing to develop a discharge plan and reevaluate as needed.

• Graduate with a Bachelor's degree in social work or related field. MSW preferred
• Minnesota State Licensure for Social Workers. LICSW preferred
• Ability to establish and maintain effective relationships with patients, their families, staff, physicians and the community.
• Sensitivity to people and their problems with a willingness to become involved professionally with another human being.
• Skill in oral and written communication.
• Prior experience in a health care setting required, hospital experience preferred.

This position is mostly days; Monday-Friday, rare evenings or weekends as needed to help support our patient's needs.