- As a member of the multidisciplinary team, assesses patients' psycho-social status, strengths and areas of need that may affect rehabilitation and optimal treatment outcomes as part of the comprehensive patient assessment.
- Conduct initial face-to-face MSW assessments, reassessments, post-hospital visits, follow-ups, and monthly visits in accordance with agency policies.
- Counsel patients and their families on ESRD modalities.
- Participates in care planning in collaboration with the patient and healthcare team to identify effective interventions that will help the patient meet rehabilitation and treatment goals, improve quality of life.
- Gather and document information to assess and modify care plans while adhering to regulatory requirements.
- Ensure completeness of Social Work documentation for QAPI reporting and present findings during QAPI meetings.
- Complete KDQOL's and PHQ-2 assessments in a timely and compliant manner.
- Ensure timely completion of patient care plans.
- Document progress notes for all dialysis patients according to established Freedom at Home Dialysis guidelines.
- Maintain accurate and complete documentation of all relevant information in medical records, following established policies and federal and state regulations.
- Assesses patient knowledge of kidney disease for barriers that may affect adherence to treatment. Works with patient, family and health care team to provide education tailored to the patient's learning style and needs.
- Guide patients through the enrollment process for organ transplant programs.
- Assist patients and families in completing financial (insurance) forms to maintain participation in the staff-assisted dialysis program.
- With other members of the interdisciplinary team and TOP (Treatment Options Program), provides appropriate information about all treatment modalities. Within the social work scope of practice, collaborates with the interdisciplinary team and transplant center to refer and track patient transplant referrals.
- Provides ongoing education to patient/family regarding psycho-social issues related to End Stage Renal Disease (ESRD) and all support services that are available.
- Understands the referral and admission process and works with Central Local Intake Process (CLIP) office staff, the Clinical Manager and facility team regarding patient needs for scheduling to maximize adherence and adjustment.
- Collaborate closely with the billing department and follow up on insurance changes or updates with patients.
- Promote the FAHD staff-assisted dialysis program and counsel hospital and LTACH case managers and patient families on FAHD Admission Qualifiers as needed.
- Collaborate with attending nephrologists or hospital case managers to effectively manage hospitalized staff-assisted patients, ensuring timely resumption of care.
- Act as a liaison between the hospital, physicians, nursing homes, and patient families to resolve problems, provide information, and maintain positive relationships.
- Interface with facility or hospital utilization review staff to facilitate proper coordination of care, transitions between care settings, and discharges.
- Collaborate with the interdisciplinary team to ensure safe and clean work areas.
- Ensure appropriate and timely patient transfer of service from the staff-assist program to in-center dialysis.
- Assess patients' home medical support needs to ensure dialysis treatment compliance and prevent hospitalization.
- Coordinate with hospital case managers or social workers during patient hospitalization to ensure readiness for a return home and prevent re-hospitalizations.
- Ensure the timely completion of interdisciplinary care plans per state guidelines.
- Participate in operational programs, including attending QAPI meetings and in-service meetings.
- Collaborates with facility team to ensure that all required admission documentation is prepared and forwarded to the Billing Department for processing.
- Master's Degree in Social Work with a concentration in clinical practice from a school of Social Work accredited by the Council on Social Work Education (CSWE).
- Licensure: Current Texas License in Social Work; Texas Driver's License
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Full-Time LMSW - Rockwall, United States - Freedom At Home Dialysis
1 month ago
Description
Company Description"Freedom At Home Dialysis is a committed team of Healthcare professionals dedicated to the ethical pursuit of improving the quality of life of all our patients and presenting ourselves as advocates and leaders in our profession."
Freedom At Home Dialysis - the leader in Staff Assisted Home Dialysis in the Dallas/Fort Worth area understands that choosing a career in healthcare is often personal. Whether it is because of your love of people and your desire to make a difference in the lives of others, or your need to become part of a team, we understand the passion and dedication it takes to be that special someone. It's these qualities that make our people our greatest asset. And in turn, we believe in developing the best through appreciation and encouragement.
Job Description
Patient Assessment/Care Planning/ Counseling:
EDUCATION
Experience with renal patients required
Experience: Minimum of one (1) year experience in the field of dialysis social work
Skills: Working knowledge of community resources. Self-motivated. Good interpersonal skills. Proficient in Microsoft Word, Excel, PowerPoint
Additional Information
All your information will be kept confidential according to EEO guidelines.
All applicants will be required to pass a criminal background check.
