• Participates in the assessment of patients' biopsychosocial needs through review of patient information, personal contact with patients/families and interdisciplinary care team members. Communicates routinely with patients, families, interdisciplinary care team members and other appropriate parties with regard to the status of patients' care plans. progress toward treatment goals, identification of concerns and/or problems, problem solving and assisting with conflict resolution when necessary.
• Ensures that all options available to support a successful transition and elements critical to patients' care plans have been communicated to patients/families and members of the healthcare team and are documented as necessary to ensure continuity of care. Refers cases and issues appropriately to resolve barriers to care progression. Acts as an advocate for patients to resolve barriers to care progression.
• On the basis of preliminary risk screenings, assesses the psychosocial risk factors of patients/families through the evaluation of prior functional levels, appropriateness/adequacy of support systems, reactions to illnesses and the ability to cope.
• Intervenes with patients/families regarding emotional, social and financial consequences of illness and/or disability.
• Serves as a resource person and provides counseling and interventions related to treatment and end of life decisions. Advocates for patient/family empowerment and independence to make autonomous healthcare decisions and access needed healthcare services.
• Provides discharge planning and continuity of care for assigned patients in the acute and post-acute settings.
• Initiates and facilitates referrals to clinics, home healthcare, hospice, SNF, acute rehab, LTAC, TCM, medical equipment and supplies as indicated.
• Collaborates with the interdisciplinary care team, patients and families in the assessment/coordination of discharge planning needs, delivery of post-discharge planning needs, delivery of post-discharge services and transition of patients from the hospital to the discharge setting as well as ongoing care in the community.
• Documents relevant discharge planning information in the medical record according to department standards and/or care management plans. Collaborates/communicates with internal/external Case Managers.
• Provides coordination of services and acts as a key Liaison between patients, families and the interdisciplinary healthcare members.
• Performs other duties as assigned.

Requirements:

• MSW in Social Work
• Basic Life Support through the American Heart Association
• One year of experience in clinical care or clinical case management