OverviewProvides targeted social work services to patients at high risk for rehospitalization during a transitional care episode in the Transitional Care Program. Functions as part of a nurse practitioner-led team providing services to this population. Works under general supervision.
Compensation:null
What We Provide
- Per Diem team members can access our extensive Employee Assistance Program that includes financial, legal, and mental health counseling program as well as participate in a retirement savings program
What You Will Do
- Collaborates with the transitional care team to perform interventions during post hospital discharge period aimed at reducing preventable hospitalizations.
- Makes home visits to patients in the program after hospital discharge with defined social service needs and develops a plan for the transitional care episode in collaboration with the program team.
- Conducts weekly or more frequent phone visits to the patient and family/caregiver with defined social service needs. Telephone monitoring is for the purpose of patient assessment, monitoring and self management education and support.
- Establishes the social work component of the client/family plan of care based on goals mutually acceptable to the client, family and significant others. Makes referrals to other community services, as necessary.
- Travels to patients’ homes and/or other facilities with varying environments (e.g., elevated buildings, walk-ups, care facilities, single/multiple family homes, presence of pets, etc.) using approved transportation options to deliver direct service to the client.
- Provides psychosocial work services to client and/or family, including short-term individual counseling, community resource planning, crisis intervention and assistance in obtaining entitlements and community services.
- Assesses clients and /or family psychosocial status, social work needs and living conditions utilizing professional knowledge, observation skills and interviewing skills.
- Assesses the need for ongoing psychiatric care and assures the transition to a primary psychiatric provider.
- Initiates and maintains verbal and written communication, including the preparation of clinical and progress notes, to ensure optimal quality client care and continuity.
- Maintains productivity sufficient to meet program goals.
- Assists team members in understanding the significant social and emotional factors related to the client’s health problems.
- Uses an electronic medical record to document appropriate social work interventions and to allow reporting and outcome evaluation measures.
- Participates in the development of a treatment plan and revises the goals as needed. Coordinates approaches to client and/or family care with other team members.
- Consults with and educates the client and family regarding the treatment plan, self-care techniques and prevention strategies.
- Acts as a program representative at institutional and community programs and functions. Provides information as needed about the program and services. Provides continuous feedback on the social work clinical model and participates in program modification efforts.
- Participates in discharge planning from the Transitional Care Program.
- Assumes responsibility for continued professional growth, such as in-service programs.
- Depending on the site of provision of care, transports and utilizes designated/supplied carrying case weighing up to 30 lbs. (as needed) to and from patient homes/care facilities, program offices and other locations.
- Participates in regular case conferences that result in refinement of the social work services delivered in order to meet program goals.
- Participates in the orientation of new Licensed Clinical Social Workers and other program staff and acts a preceptor for new staff.
- Participates in special projects and performs other duties as assigned.
QualificationsLicenses and Certifications:
- Current registration to practice as a Licensed Clinical Social Worker (LCSW) in New York State Required
- Valid driver's license as determined by operational/regional needs may be Required
Education:
- Master's Degree in Social Work required
Work Experience:
- Minimum of four years social work experience as a direct clinical service provider and/or discharge planner in a health care setting required
- Experience with chronically ill patients preferred
- Bilingual skills as determined by operational needs may be required
