Social Worker - Full Time
The Social Worker functions as a member of the interdisciplinary team and aids patients/families as they transition from the hospital to the community through safe and effective discharge planning. The Social Worker facilities a relationship with family members, identifying stressors interfering with their perception of the hospital stay and communicating the needs, perceptions, concerns, & family goals to the team. The Social Worker facilitates effective communication between the team and the family as the patient moves through the process of admission to discharge.
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- Performs social service screening, psychosocial assessment, and discharge planning assessment on each patient admitted or readmitted to the hospital within 72 hours of admission.
- Includes all elements in the assessment per policy.
- Writes assessment in the medical record clearly and succinctly.
- Develops a plan of care for social services as part of the psychosocial assessment.
- Incorporates plan of care into the interdisciplinary care plan.
- Updates care plan in a timely manner (weekly as part of the team conference report).
- Identifies those patients and family members who need counseling.
- Interacts with patients and significant others in a warm, empathetic, and accepting manner.
- Helps patients and significant others to focus on and resolve issues of importance.
- Coordinates with the case manager and physician to facilitate family conferences upon admission and for discharge planning.
- Works closely with clinical disciplines on mandatory family education (care by a parent) before discharge.
- Documents progress in the medical record.
- Documents discharge barriers in the medical record.
- Locates appropriate community resources.
- Informs patient and/or significant others about referrals both verbally and in writing.
- Assists team in the development of the appropriate level of care needed for the patient upon discharge.
- Communicates to patient/family the team recommendation of the level of care after each team conference.
- Communicates pertinent information regarding patient care to other staff members.
- Reviews interdisciplinary care plans and acts as a patient/family advocate when patient/family are unable to attend.
- Coordinates family conferences, per hospital policy, for those parents that request a verbal update after treatment conferences.
- Communicate discharge barriers to the team to ensure early intervention towards CPS referrals.
- Initiate early intervention to CPS should discharge barriers be too significant to resolve.
- Maintains care provider relationships for discharge planning and referral sources.
- Performs other duties as assigned.
- Minimum two years experience as a Social Worker / Case Manager.
- Prefer in a medical setting
- Bachelor’s degree in Social Work.
- Masters preferred.
- Current license in social work from the state of Texas.