General Duties
- Assist the patient and family with social, emotional and family problems precipitated by illness and hospitalization.
- Encourage optimum utilization of health care and resources.
- Serve as liaison between the Hospital, Long Term Care Facilities, Alternative Care Facilities and other resources in the community.
- Develop a discharge plan of care with the patient and family/responsible party.
Functions and Areas of Responsibility
- Maintain goals on patient care plan and update as needed.
- Discusses Advance Directives; assists obtaining copies for facility and/or in facilitating one; evaluates if Advance Directives need to be reviewed due to a change in status; and assists with monitoring for presence of Advance Directives in chart.
- Identifies psychosocial needs and preferences, customary routines, concerns and choices.
- Complete a social history, Social Service Assessment.
- Provide supervision to social work interns.
- Assist patients as needed with financial and legal matters.
- Provide support and guidance on a continuing basis to patients and families as needed.
- Serves as an advocate for patients and assists with problems referred to Social Services by other departments.
- Coordinates supportive care for terminal patients.
- Keeps abreast of local, state and federal regulations and current legislation, trends and resources as they pertain to Social Services in health care settings.
- Plans and implements C.Q.I. plan for department.
- Facilitate and help guide interdisciplinary care rounds Monday-Friday.
Care Navigator
- Collaborates with the health care team and community care providers to ensure that an effective and timely transition in level of care is implemented upon discharge.
- Provides medical and pre-op/postop surgical patients with education, advocacy, and decision making support related to the impact of medical illness, social/functional/financial needs on healing, recovery, chronic care, or end of life care.
- Engage patients as active participants in the planning of their recovery process, elevate the information from and access to their providers, and empower patients toward long-term health and wellness upon discharge.
Discharge Planning
- Check discharge needs/assessment in patients' chart for data. Identify patients who need discharge planning.
- Arrange for a multidisciplinary care conference as needed.
- Arrange for alternative living arrangements if needed.
- Arrange for services and/or equipment if needed.
- Communicate and work with nursing to develop a discharge plan and reevaluate as needed.
Orthopedic Center of Excellence skills as listed below to include Hip, Knee, Shoulder and Spine procedures.
- Identify patients who need discharge planning, send referrals as needed
- Provide resources to patients for outpatient needs such as therapy, home care, and equipment.
- Attend Joint Camp as needed
- Education per current DNV requirements as defined by CR.5 DNV regulatory guidelines. Education to include two hours on hire and annually.
Physical Demands/Requirements
The below requirements are intended to describe the general context/requirements for performing this job. It is not to be considered as an extension of statement of duties, responsibilities, or requirements and does not limit the assignment of additional duties.
Legend: Continually: 5.5-8 hrs/day Frequently: 2.5-5.5 hrs/day Occasionally: .5-2.5 hrs/day
a) Continual talking/hearing in person/on phone, and vision for close work.
b) Frequent stationary standing, walking, ability to be mobile, keyboarding and repetitive hand movements.
c) Occasional sitting, crouching, turning/pivoting, reaching overhead, grasping, pushing/pulling, lifting/carrying and the need for color vision.
d) This position does not require repetitive lifting/carrying or pushing/pulling in excess of 30 pounds.
