Social Worker

Overview

As a member of the interdisciplinary team, Social Workers contribute professional and clinical knowledge and skills to support patient and family access to health care resources. In addition, social workers provide assessment of psychosocial factors that influence a patient’s health with connection to community resources to alleviate barriers. Works in various areas of the hospital setting providing direct care and emotional support, transition planning and facilitation, and advocacy.

Responsibilities

Patient Care :

Performs psychosocial assessment of the patient to identify priority needs, strengths, patient preferences and barriers to care.

Provides immediate crisis intervention and support to patients / families to enhance their ability to cope with the impact of health conditions.

Educates patient / family regarding Advanced Directives and refers them to trained facilitators for conversations and completion of Advanced Care Planning documents with patients / surrogate decision makers including First Steps and IPOST / IPOLST.

Assesses grief issues and offers bereavement support.

Assists with planning for care transitions and collaborates with UPH, community services, and facilities to support patient safety and continuity of care.

Completes PASRR or other screening tools when appropriate for transition to another care provider.

Establish a psychosocial treatment plan for patients exhibiting complex emotional and behavioral problems. Works collaboratively with physicians and Behavioral Health professionals to support the patient and family through this acute episode of care and support them through transition.

Documents assessments, interventions, and referrals in the electronic health record according to documentation standard.

Education and Advocacy :

Serves as a patient / family advocate in support of patient confidentiality, informed consent, patient autonomy, and self-determination.

Assesses patient safety to identify possible abuse, neglect or other risks to safety. Collaborates with the care team to address safety issues and files DHS reports and / or guides others in the process as mandated.

Provides information and support with guardianship and conservatorship issues.

Supports culturally competent services and assists with arranging interpreter services as needed.

Provides education to the patient / family regarding available services and supports and assists the patient to access those they are eligible for.

Provides information and education to physician and other team members in understanding the psychosocial implications of illness and disease progression for the patient / family.

Participates in mentoring new employees and / or supervising BSWs and social work interns as requested.

Care Coordination / Transition Support :

Identifies patient transitional needs by assessing psychosocial, environmental, financial and cultural strengths and barriers.

Maintains comprehensive knowledge of community resources and acts as a liaison to refer patients / families to health and social services, health insurance, public assistance and other resources to meet patient identified needs.

Provides expertise and plays a key role with the care team in establishing patient-centered goals of care and identifying psychosocial and behavioral strengths and barriers.

Contributes to the comprehensive, longitudinal plan of care based on patient-centric goals and coping strategies.

Facilitates and / or participates in interdisciplinary team meetings to review and revise the patient plan of care.

Facilitates patient / family meetings to enhance family support of the patient’s care.

Collaborates with social workers and other professionals across the continuum and in the community to ensure continuity of care.

Qualifications