• Identify Cases & Prioritize Day - Review and prioritize consults received. Participate in Daily Case Management Touchpoint per established protocols. In Communication and Patient Progression (CAPP) Rounds identify patients who require a SW consult and collaborate with the interdisciplinary team regarding findings/needs.
• CAPP Meeting - Attend and actively participate in CAPP meetings for assigned units to provide and receive information on patients’ progression and psychosocial needs. Complete follow-up from CAPP as appropriate. For CAPP that the Social Worker cannot attend, communicate psychosocial, discharge and plan of care barriers to team members for discussion, as necessary meet with the team member after the meeting to obtain updates and action items.
• New Consults - Complete and document a psychosocial assessment to include Social Determinants of Health (SDOH) within 24 hours of receiving the consult and communicate recommendations back to the Multidisciplinary Team. Determine and document a plan of care as a part of the psychosocial assessment in the EMR.
• Active Consults - Document social work note/reassessment. Discuss with appropriate members of the multidisciplinary team when there are barriers to discharge and psychosocial concerns affecting progression of care or readmission risk. Utilizes motivational interviewing to identify barriers and facilitate care plan compliance. Serves as a patient advocate, supporting shared decision-making and the use of decision aids. Coordinate family meetings, as necessary, to support the progression of care. Provide education on community resources, support/educational groups, and any other appropriate resources to patient, family, and care team. Educate and/or coordinate referrals to community resources and post-acute providers as necessary. Identify patient’s readiness to discharge based on discussions with the patient/family/care team on an ongoing basis. Assess the discharge plan to determine needs post-discharge and communicate to patient/family/care team on an ongoing basis. Identify required authorization for post-discharge services and refer to the appropriate post-discharge service provider. Participate in medication resource management for non-resourced patients, as needed. Verify patient’s understanding/agreement of discharge plan. Escalate urgent or complex cases to appropriate Case Management leadership according to established departmental escalation process.
• Professionalism - Demonstrates flexibility and professionalism in a dynamic environment with frequent re-ordering of priorities and assignments. Uses critical thinking skills to evaluate and prioritize rapidly changing demands, working collaboratively to best accomplish the team’s mission.
• Documentation - Documents activities, events, and information per standards in established software systems in a timely, accurate, and complete manner. Identifies Avoidable Delays and documents causes for delay consistent with department standards.
• Confidentiality - Uses established policies and processes to handle, discuss, and transmit protected health information in manner consistent with privacy and compliance expectations and policies.
• Compliance and Performance Improvement - Uses departmental guidelines and job aids to perform work in an accurate, compliant manner consistent with known and written expectations and work rules. Participates in process improvement initiatives, which may include helping with the creation/revision of guidelines, training tools, and job aids. Maintains current knowledge of institutional and departmental expectations for job performance through attendance at meetings, review of meeting minutes and guidance documents, and independent review of institutional and departmental policies and guidelines as needed. May assist with training/pre-cepting as needed/assigned.
• Demonstrates effective communication, consultation, negotiation, and collaboration skills with all members of the staff and other stakeholders.
• Excellent problem solving skills.
• Uses effective conflict resolution techniques.
• Works harmoniously with team members.
• Excellent problem solving skills.
• Role Model and adheres to the Code of Conduct.
• Assesses and responds appropriately to organization culture.
• Maintains privacy and confidentiality of all appropriate information.
• Takes responsibilities for outcomes of his/her efforts. Recognizes work as a reflection of him/herself.
• Works toward a common purpose to serve our patients and community.
• Adheres to organizational policies.
• Attends education/mandatory sessions in a timely manner.
• Excellent organizational skills.
