Social Worker LSW - Weymouth, United States - South Shore Health

Description

Job Description Summary Under the general supervision of the Care Progression Manager acts as a patient advocate / Social Worker LSW to SSH&EC clients. Works in coordination with the RN Case Manager to coordinate, negotiate, procure services and resources for and manage the transitional care planning of patients to facilitate achievement of quality and cost efficient patient outcomes. Responsible to work with a multi-disciplinary patient care team to optimize the discharge planning mission for patients, from admission to discharge, which requires varying degrees of follow-up and follow through, including fostering, executing, and expediting and efficient and effective discharge process. Works collaboratively with the interdisciplinary staff internal and external to the Organization. Participates in quality improvement and evaluation processes related to the management of patient care. The Social Worker LSW is on site and available seven (7) days a week as well as holidays and therefore, is required to work a weekend rotation and also an occasional holiday.

Job Description

ESSENTIAL FUNCTIONS

- Working collaboratively with the RN Case Manager, the Social Worker LSW coordinates and facilitates discharge planning to patients within a defined caseload.

2 -The Social Worker LSW works with the RN Case Manager to identify and prioritize workflow through identification of patient specific needs, department needs and or unit based needs.

3 - The Social Worker LSW performs patient discharge planning assessments to identify needs, issues, resources, and care goals, and brings any identified complex patient care issues that may pose a barrier to timely discharge planning or transition to the attention of the RN Case Manager for case review.

4 - The Social Worker LSW engages and utilizes the clinical expertise of the RN Case Manager as a resource to procure and support a high-quality discharge plan.

a - Executes and implements a safe and effective discharge plan based on the case management assessment in accordance with the Conditions of Participation.

b - Makes and documents appropriate changes to discharge plan when necessary.

c - Proactively uncovers barriers to early/timely discharge and overcomes them.

d - Uses and updates the interdisciplinary patient White Board for communication enhancement; including Social Worker LSW name, time/date/plan for discharge.

e - Issues the Medicare IM.

f - Completes the Medical Necessity form for post discharge transportation.

g - Identifies Care Plan Partners.

h - Identifies patient Health Care Proxy's or establishes as needed.

i - Attends multidisciplinary rounds.

j - Fosters patient and family awareness of Patient Portal.

5 - Communication: The Social Worker LSW is aware of his/her capabilities and limitations and seeks advice/direction from RN Case Manager through the use of huddles as needed throughout the workday.

a - The Social Worker LSW communicates the safe and effective discharge plan to clinical staff, patient, family, and caregivers; incorporating additions and changes to the discharge plan

b - Escalates any patient questions and / or concerns to the RN Case Manager as need arises.

c - Refers any payer negotiation to the Care Progression Manager or RN Case Manager.

d - Escalate any provider concerns related to payer issues, or clinical concern to the Care Progression Manager or RN Case Manager.

e - Acts as a communication liaison between all members of the care team and the patient/family as it may pertain to discharge choices, concerns, barriers.

f - Maintains up to date communication with whole team as to discharge plan progress and/or delays.

g - Maintain up to date documentation reflective of changes who, and why the changes were made in EMR.

h - Uses SBAR to communicate with peers

i - Updates all outside tertiary providers via Edischarge, telephone, fax or other when a change in discharge plan impacts the place and date of transfer

j - Understands the need to works with the RN Case Manager if patient condition and medical complexity changes which is impacting length of stay.

Facilitate coordination and documentation of discharge appointments

6 - Ensure that patient has received all information related to choice of follow-up care facilities, and/or public or private care providers, including explaining all elements of discharge, continuum of care needs and available options to patients, families and/or care givers.

a - Ensure that, at minimum, 3 referrals are processed for continuum of care providers.

b - Document choices provided and selections made by patient and/or family.

c - Expedite and process referrals, in a timely manner to department standards, including requesting and tracking screenings and acceptances of patients by care providers, expediting responses from provider facility personnel as necessary.

d - Document response by providers.

e - Delivers the Medicare Important Message (IM) per department protocol.

f - Have patient, family/healthcare Proxy sign discharge plan.

7 - Reference resources to confirm provider benefits for care choices, including public, private, and governmental payers and established / preferred ACO relations.

a - Maintains current knowledge of discharge planning, as specified by federal, state, private insurance guidelines

b - Maintains a working knowledge of the resources available in the community for patient/family.

c - Maintains a working knowledge of the requirements of the payers most frequently seen with the patient population

d - Maintains a working knowledge of the established and preferred ACO relationships as defined in service area.

8 - Complete and process required documentation, such as discharge plans, and government program forms to meet discharge plan metrics.

a - Complete Long Term placement forms as required in a timely fashion as to not delay any transfer.

b - Process and confirm the completion of Comfort Care forms, when applicable, as to not delay any transfer.

c - Complete any other patient related documentation to comply with legal and hospital requirements for discharge, and secure necessary signatures, patient and otherwise.

d - Confirm the presence of Health Care Proxy forms, if appropriate.

e - Obtain all required patient signatures.

f - Confirm the presence of all necessary documentation, such as discharge summary, medication reconciliation, etc.

g - Arrange for post discharge procurement of the following, when needed: Lovenox, Zyvox, CPM, DME, Wound Vac.

9 - Arrange for and confirm transportation needs

a - Communicate with Discharge Liaison, on a timely basis, to provide projected number of, and time of daily projected discharges, and type of transportation needs will be required.

b - Notify patient/family/care plan partner 24 hours prior to discharge, and confirm transportation appointments.

10 - Attains all agreed to goals and objectives within specified time frames, as part of the organizations overall mission.

11 - Along with the RN Case Manager, is responsible for department operational excellence, regarding safe and effective discharge planning; assures department delivers quality services in accordance with applicable policies, procedures and professional standards.

a - Manages all activities so that quality services are provided in an efficient and effective manner.

b - Participates in departmental and organizational Quality Improvement initiatives involving the Lean principles and TIM WOODS

c - Has an awareness of departmental productivity measurements including LOS and utilization.

d - Follows department policies, procedures, and standards of care that support operational excellence and productivity measurements

12 - Technology - Embraces technological solutions to work processes and practices.

a - Edischarge, Morrisey, Epic, Workday and others.

13 - Safety Awareness - Fosters a "Culture of Safety" through personal ownership and commitment to a safe environment.

14 - Support the vision and mission of South Shore Hospital and those of the case management department.

a - Demonstrated professional behavior in attitude, attendance, performance, and attire.

JOB REQUIREMENTS

Minimum Education - Preferred

BS in Psychology, Social Work, Communications or health related field preferred. Demonstrated competency in basic computer and keyboard skills required, Epic and Workday preferred. Knowledge of basic medical terminology preferred, or completion of course within first year of hire.

Minimum Work Experience

Recent healthcare experience or related field preferred.

Experience within an admissions and/or discharge function desirable, especially in a high stress area, Experience working with patients and families, elders and their caregivers, and/or various other community populations desirable.

Nursing level or social worker experience desirable.

Required License/Certification

LSW - Licensed Social Worker

Required additional Knowledge, and Abilities

Excellent communication skills required; ability to work independently and under very stressful situations required. Ability to time manages . click apply for full job details