Title: Hospital Social Worker

A Day in the Life includes:

• Screens referrals according to department policy and procedure for identification of high-risk patients in need of or requesting social service intervention.
• Attends multidisciplinary plan of care meetings & daily care coordination rounds on assigned units.
• Initiates social service intervention within one (1) business day of admission/referral on patients that meet the departments established high-risk criteria.
• Responsible for the completion of the psychosocial assessment and coordination of a safe and appropriate discharge plan in collaboration with other members of the health care team.
• Assess and evaluate post hospital needs through interview and assessment of patient and/or family/significant other and formulate a discharge plan that appropriately addresses the physical, social, economic and emotional needs of the patient. Evaluate needs taking into consideration the patient's current medical problems, past medical, psychosocial and cultural history, and community support system. Evaluate appropriateness of plan and makes revisions as necessary based on ongoing reassessment of patient's needs.
• Utilizing the teach back method, elicits and documents patient's and/or family's/significant others understanding of, and agreement with the discharge plan.
• Provides limited counseling and crisis intervention services to patient and/or family.
• Makes available referrals to outside agencies/support groups when appropriate.
• Maintains ongoing communication with the patient, family/significant other, physician, nursing staff, discharge planning nurse, utilization review nurse, and/or other members of the healthcare team concerning the status of the discharge plan and documents such in the medical record.
• Investigates insurance coverage as needed for continuum of care needs and assesses the adequacy of the patient's insurance coverage.
• Initiates entitlement program referrals when appropriate and needed.
• Communicates verbally and in writing with third party payors as appropriate to obtain all necessary authorizations and facilitate the discharge plan.
• Implements the agreed upon discharge plan by coordinating referrals to the appropriate community agencies, services, programs and facilities.
• Reports identified problems to the assistant director and submit written report according to department policy and procedure.