Social Worker, Discharge Planning

Job Description
General Summary
Under limited oversight, functions as a member of the multidisciplinary healthcare team to provide case management, crisis intervention, evaluation, counseling, referral, planning, and other treatment services within their practice area. Maintains working knowledge of available community resources and evidence-based practices to target the diverse psychosocial and emotional needs of patients, families, and groups.
Principal Responsibilities and Tasks
The following statements describe the general work performed in this role. It is not an exhaustive list of all duties that may be performed.
Completes psychosocial assessments, incorporating the results of screening tools administered to develop an appropriate plan(s) of care.
Autonomously proposes &
executes safe, appropriate, and timely plan of care and/or discharge plan patients, families, and multidisciplinary healthcare team. Seeks assistance from a supervisor and/or interdisciplinary team as needed.
Administers crisis intervention, as necessary, and demonstrates expert use of social work skills within the individual’s specialty to provide trauma informed care related to the patient’s social determinants of health.
Evaluates effectiveness of patients’ response to social work intervention, individual social work practice, and programs within the organization. Participates in performance improvement initiatives.
Shares resources with patients, families, and co-workers. Maintains a current list of relevant community resources. Demonstrates flexibility and creativity when identifying appropriate community resources for patients and their families.
Maintains a working knowledge of relevant medical, cultural, social, legal, and other issues that could impact patient care. Conducts chart reviews to gain an understanding of past referrals and utilization of services. Coordinates and documents appropriate referrals and keeps patient, family, and care team informed of referrals made.
Facilitates individual, family, and/or group counseling utilizing brief therapy models (Dialectical Behavioral Therapy, Cognitive Behavioral Therapy, etc) to support patients’ goals, with consideration of emotional and mental health disorders identified in the DSM.
Serves as a liaison with outside agents and other departments to improve coordination and consultation of patients’ care, while obtaining appropriate Releases of Information and maintaining confidentiality as it relates to HIPAA.
Conducts individual and group education sessions. Serves as an educational and training resource to SW I &
SW II within their practice area.
Acts as a liaison between the patient, family, treatment team, and other departments in service of furthering equitable patient-centered within the healthcare delivery system.
Recognizes and identifies systemic challenges impacting individual patients and the impact to their health, well-being, and access to care. Works to empower change to address equity within the healthcare and community systems in which the patients exists. Explores strategies to reduce resource consumption for target populations;
implement and evaluate outcomes.
Performs departmental administrative duties.
Completes all specific job tasks within their assigned department as outlined by supervisor.