The Social Worker functions as a member of the interdisciplinary team and aids patients/families as they transition from the hospital to the community through safe and effective discharge planning. The Social Worker facilities a relationship with family members, identifying stressors interfering with their perception of the hospital stay and communicating the needs, perceptions, concerns, & family goals to the team. The Social Worker facilitates effective communication between the team and the family as the patient moves through the process of admission to discharge.
Job Specific Responsibilities:
• Performs social service screening, psychosocial assessment and discharge planning assessment on each patient admitted or readmitted to the hospital within 72 hours of admission.
• Includes all elements in the assessment per policy.
• Writes assessment in medical record in clear and succinct manner.
• Develops plan of care for social services as part of the psychosocial assessment.
• Incorporates plan of care into the interdisciplinary care plan.
• Updates care plan in a timely manner (weekly as part of the team conference report).
• Identifies those patients and family members who need counseling.
• Interacts with patients and significant others in a warm, empathetic, and accepting manner.
• Helps patients and significant others to focus on and resolve issues of importance.
• Coordinates with the case manager and physician to facilitate family conferences upon admission, and for discharge planning.
• Works closely with clinical disciplines on mandatory family education (care by parent) prior to discharge.
• Documents progress in the medical record.
• Documents discharge barriers in the medical record.
• Locates appropriate community resources.
• Informs patient and/or significant others about referrals both verbally and in writing.
• Assists team in development of the appropriate level of care needed for the patient upon discharge.
• Communicates to patient/family the team recommendation of the level of care after each team conference.
• Communicates pertinent information regarding patient care to other staff members.
• Reviews interdisciplinary care plans and acts as a patient/family advocate when patient/family are unable to attend.
• Coordinates family conferences, per hospital policy, for those parents that request a verbal update after treatment conferences.
• Communicate discharge barriers to the team to ensure early intervention towards CPS referrals.
• Initiate early intervention to CPS should discharge barriers be too significant to resolve.
• Maintains care provider relationships for discharge planning and referral sources.
• Performs other duties as assigned.
• Bachelor’s degree in Social Work.
• Masters preferred.
• Minimum two years’ experience as a Social Worker / Case Manager.
• Prefer in medical setting
• Current license in social work from state of Texas.