Post-Acute Transitional Social Worker

POSITION DESCRIPTION:

The Post-Acute Transitional Social Worker is an integral member of the ambulatory care team.  This position is responsible for addressing social needs for patients in post-acute settings including, but not limited to, skilled nursing facilities, long-term care hospitals, inpatient rehabilitation facilities, home health agencies and patients’ homes in multiple counties in Southeast Michigan. Specific focus on patients requiring care in a Skilled Nursing Facility (SNF), the Post-Acute Transitional Social Worker duties will include on-site assessment and collaboration with SNF social workers, patient and family to ensure a safe discharge to next level of care for patients.  The Post-Acute Social Worker will do home visits as needed to assess needs in the home, caregiver support and community resources.   The social worker, in collaboration with the Post-Acute Transitional Care Manager, will communicate with the primary care team to ensure a seamless handoff to longitudinal care management, when appropriate.  

ESSENTIAL JOB FUNCTIONS:

1. Obtains a thorough assessment of the patient that includes current clinical status, family and caregiver support, social determinants of health, and patient and caregiver goals for discharge.
2. Assesses the family's knowledge base, expectations and the ability for a family member to act as the primary caregiver, if appropriate.
3. Assists the individual, the family and team in identifying the variables that may influence the accomplishment of goals.
4. Supports the development of a realistic and safe discharge plan with the care team, Post-Acute Transitional Care Manager and patient/family.
5. Develops a strong team-oriented relationship with the rehabilitation team within the post-acute setting to ensure the patient’s plan of care is being carried out in a timely manner.
6. Participates in conferences that provide ongoing evaluation of interprofessional dynamics, goal attainment and treatment plan revision.
7. Responsible for supporting the patient care plan in collaboration with the patient and interdisciplinary care team which includes the treatment plan, disposition, progress, anticipated needs and expected length of stay. 
8. Promotes effective communication among the healthcare team members, including the patient, family, interdisciplinary team, case managers and primary care physician.
9. Serves as a liaison between the patient, physician, care team and the discharge planner by coordinating, monitoring, and communicating the patient’s goals and progress, and assisting with coordination to the next level of care.
10. Facilitates and collaborates with the healthcare team for timely discharge planning to an alternate level of care or return to the individual’s previous level of care.

1. Coordinates appropriate resources and supportive services to meet the patient’s needs at the time of transition to next level of care, based on collaboration with the healthcare team recommendations.
2. Once patient transitions to next level of care, to ensure a smooth transition, performs home visits as appropriate working with the Post-Acute Transitional Care Manager to determine priority.  
3. Addresses patient ethical and legal issues such as advanced directives, end of life decisions and guardianship.
4. Refers patients to appropriate community agencies to access services to meet patient’s psycho-social needs. 
5. Provides verbal and written education to the individual and family regarding community resources and supportive services.
6. Other duties as assigned.

ORGANIZATIONAL EXPECTATIONS:

1. Creates a positive, professional, service-oriented work environment for staff, patients and family members by supporting mission and values of both IHA and Trinity Health.
2. Must be able to work effectively as a member of the clinical team.
3. Assumes responsibility for performance of job duties in the safest possible manner to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management.
4. Successfully completes IHA’s “The Customer” training and adheres to IHA’s standard of promptly providing a high level of service and respect to internal or external customers.
5. Maintains knowledge of and complies with IHA standards, policies and procedures.
6. Maintains complete knowledge of office services and in the use of all relevant office equipment, computer and manual systems.
7. Maintains strict patient and employee confidentiality in compliance with IHA and HIPAA guidelines.
8. Serves as a role model by demonstrating exceptional ability and willingness to take on new and additional responsibilities.  Embraces new ideas and respect cultural differences.
9. Uses resources efficiently.
10. Responsible for ongoing professional development – maintains appropriate licensure/certification and continuing education credentials, participates in available learning opportunities.

MEASURED BY:

Performance that meets or exceeds IHA CARES Values expectation as outlined in IHA Performance Review document, relative to position.  Care Management Metrics including productivity and ACP education and completion, and others defined by program.

ESSENTIAL QUALIFICATIONS:

EDUCATION:  Bachelor of Social Work from a school accredited by the Council of Social Work Education.  

CREDENTIALS/LICENSURE:  Valid, unrestricted license to practice social work in the State of Michigan; Valid CPR certification.

MINIMUM EXPERIENCE:   Minimum of 2 years of experience in social work setting with vulnerable populations.

POSITION REQUIREMENTS (ABILITIES & SKILLS):

1. Knowledge of patient care procedures and organizational policies related to position responsibilities.
2. Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment and patient education
3. Applied understanding of how social determinants affect health and demonstrated ability to problem-solve.
4. Proficient/knowledgeable in medical terminology.
5. Proficient in operating a standard desktop and Windows-based computer system, including, but not limited to, electronic medical records and other care management and/or clinical IS systems, email, e-learning, intranet, Microsoft Word and Excel, and computer navigation needed to complete the tasks of clinical care and performance reporting.  Ability to use other software as required while performing the essential functions of the job.
6. Excellent communication skills in both written and verbal forms, including proper phone etiquette.  Ability to speak before groups of people, either in-person or virtually.
7. Ability to work autonomously and collaboratively in a team-oriented environment, recognizing impact of treatment goals, utilization and outcomes.
8. Ability to work effectively with various levels of organizational members and diverse populations including IHA staff, providers, provider leadership, patients, family members, insurance carriers, vendors, external customers and community groups.
9. Good organizational and time management skills to effectively juggle multiple priorities and time constraints.
10. Ability to exercise sound judgement and problem-solving skills.  
11. Ability to handle patient and organizational information in a confidential manner.
12. Knowledge of the compliance and quality aspects of clinical care and patient privacy and best practices in medical office operations.
13. Ability to drive to other office/practice sites and meeting and training locations, as well as hospitals, post-acute care facilities and patient homes within several counties in Southeast Michigan.
14. Successful completion of IHA competency-based program within introductory and training period.

MINIMUM PHYSICAL EXPECTATIONS:

1. Physical activity that often requires keyboarding, phone work and charting.
2. Physical activity that often requires extensive time working on a computer.
3. Physical activity that often requires handling and lifting patients, walking, standing, bending, stooping, reaching, climbing, kneeling and/or twisting.       
4. Physical activity that often requires lifting, pushing and/or pulling up to 20 pounds.
5. Specific vision abilities required include close vision, depth perception, peripheral vision and the ability to adjust and focus. 
6. Manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment.
7. Must hear and speak well enough to conduct business over the telephone or face-to-face for long periods of time in English.