Primary Location:

Address:

Shift:

Job Description Summary:

Job Description:

Position Summary and Purpose
Under the direction of the Manager and/or Director of Care Coordination the Social Worker performs activities which support the Care Coordination Department. The Social Worker promotes optimal health care outcomes in accordance with the policies procedures applicable laws and contracts philosophy mission vision and values of University of Louisville Hospital; assumes responsibility and accountability for the appropriate utilization of facilities and services and serves as a resource to physicians nurses and ancillary staff. The social worker provides psychosocial assessment discharge planning information and referral services counseling and the coordination of services which meet the health-related needs of patients of all ages including infant (birth to one year) pediatric (1-11 years) adolescent (12-18 years) adult (19-65 years) and geriatric (66-older) in an acute care setting. The major functions include assessing planning coordinating implementing monitoring educating and evaluating care. The social worker interacts with physicians advanced providers residents medical students nursing staff staff from other departments/services involved in patient care as well as with providers and community agency representatives. Must be able to adjust priorities quickly organize multiple tasks simultaneously and work interdependently with many levels of staff. Attention to detail; strong organizational interpersonal and communication skills; and innovative problem-solving skills required. Must be able to adjust work hours depending upon departmental and organizational needs as determined by the director or manager.

Essential Functions:
Conducts timely patient needs assessment to identify psychosocial needs and needs to identify barriers to discharge and potential community needs post-discharge.
In conjunction with case manager(s) develops appropriate discharge/care management plan that will result in best possible outcomes. Uses social work screening tools and information from multiple interdisciplinary sources to develop an appropriate plan.
Reassesses plan regularly and revises as needed to ensure continuing appropriateness of plan as patients condition and status change.
Documents all comprehensive social assessment reassessment and discharge plan in EMR (Electronic Medical Record) to communicate accurately and comprehensively to other care givers and according to established policies and procedures.
Coordinates care management plan by analysis of options communication with patient family treatment team insurers and providers to maximize best possible outcomes. Works to foster patient engagement in their care and commitment to discharge plan and self-care after hospital discharge.
Implements discharge/care management plan in compliance with legal and ethical standards departmental and hospital policies and procedures and utilizing adequate knowledge of financial reimbursement criteria provider and resource options and interpretation of medical data.
Under the clinical supervision of an LCSW provides crisis assessments and acute therapeutic interventions utilizing CBT DBT motivational interviewing and other treatment modalities; diagnose any identified mental illness and develop treatment plan to include ongoing support inpatient and post-discharge.
Communicates accurate complete patient information in a timely manner to patient family Patient Care Team and prospective providers to facilitate discharge plan which best meets patient and family needs. Encourages and fosters collaboration between care providers to execute effective care plans.
Provides family sessions as identified to be appropriate to enhance patient and family ability to cope with psychosocial effects of illness/hospitalization especially for complex family situations or patients with complex or special needs. Utilizes social work tools and skills to participate in the resolution and mediation of disagreements and conflicts within family/social systems as they arise in the hospital setting.
Meets with patients and/or family members at the bedside to provide psychosocial support during various stages of disease processes including death and dying. Utilizes social work methods to help patient and family cope with very emotionally demanding issues (i.e. loss of patients limb new onset diagnosis of mental illness loss of functional abilities grief and loss financial stressors).
Serves as an advocate on behalf of patients in guardianship abuse or resource issues. When appropriate refer cases to the ethics committee for review.
Evaluates departmental products procedures and services systematically to ensure continuing effectiveness and to identify needed improvements.
Provides education to co-workers hospital and medical staff and the community to provide information about departmental functions social services-related concepts and services appropriate treatment modalities trauma-informed care and community resources.
Pursues continuing education by participation in departmental or hospital-wide in-service programs or in classes workshops or conferences.
Identifies risk issues accurately and implements procedures which appropriately address risk concerns. (APS CPS MIW Guardianship duty to warn etc.)
Supervises graduate social work students as assigned; collaborates with field practicum supervisor/ University or educational institution
Participates actively in interdisciplinary patient care team meetings providing leadership to the group as needed. Offers information attained from psychosocial assessment to overcome barriers to treatment in the patients social environment and support the treatment efficacy provided in the hospital. Is accessible to the healthcare team as a resource.
Participates actively in committees as assigned assisting with projects and the work of the committee. Seeks to use social work background to bring increased awareness to the organization of the dynamic impacts of patients individual psychosocial realities and social environments on physical and mental health.
Assesses patient to identify cognitive decline depression and other social issues prior to discharge. Conducts brief interventions for patients identified as being admitted for illness/injury related to drug/alcohol abuse and referral to substance abuse treatment agencies when patients agree to treatment. Works with psychiatric services to identify appropriate inpatient psychiatric
Makes referrals and coordinates services with community-based agencies related to education mental health issues potential abuse situations financial assist or other social/environmental needs of the patients and family. Utilizing social work theories and methods assists in maximizing patient well-being in the long term and preventing psychosocial and logistic complications which could result in readmissions after discharge.
Advocates for patient/family needs in a respectful non-judgmental and confidential manner.
Spends 80% of time on assigned units and 60% of time in direct patient care.
Committed to patient satisfaction and uses appropriate tools and services recovery to meet expected patient satisfactions metrics.
Actively involved in meeting organization metrics and goals to ensure the financial security of the organization.
Works collaborative with RN-Case Managers to identify social and financial barriers and referrals to community resources and assesses those patients with high-risk indicators.
Acknowledges addresses and completes Consults to Social Worker on respective units in EMR.
Attends Care Coordination Monthly Departmental Staff Communications Meetings.
Serves as an active member of committees as needed which may include a variety of projects or topics.
Maintains an active Social Work certification in the State of Kentucky
Maintains current Basic Life Support-CPR.
Performs other duties as assigned that are aligned with the mission and purpose of the organization

Other Functions:
Demonstrates a commitment to service organization values and professionalism through appropriate conduct and demeanor at all times.

Adheres to and exhibits our core values:

*Integrity: Moral wholeness soundness uprightness honesty and sincerity as a basis of trustworthiness.

*Excellence: Outstanding achievement merit virtue; continually surpassing standards to achieve/maintain quality.

Maintains confidentiality and protects sensitive data at all times.

Adheres to organizational and department specific safety standards and guidelines.

Works collaboratively and supports efforts of team members.

Demonstrates exceptional customer service and interacts effectively with physicians patients residents visitors staff and the broader health care community.

Additional Job Description:

Job Requirements
(Education Experience Licensure and Certification)
Education:
Master of Social Work (MSW or MSSW) required.

Experience:
One (1) year hospital or healthcare social work preferred.

Licensure:
Current Licensed Clinical Social Work or Certified Social Work license in the state of Kentucky required.

Certification:
Current BLS required.

Job Competency:
Knowledge Skills and Abilities critical to this role:
Medical Terminology
Familiarity with requirements related to protected health information (PHI) and /or HIPAA
Detail oriented in gathering relevant data while attending to essential details
Strong initiative
Ability to work independently

Language Ability:
Must be able to communicate effectively in both verbal and written formats.
Must be comfortable speaking to groups such as with committee meetings
Must have ability to interpret an extensive variety of instructions and deliver results.

Reasoning Ability:
Must have ability to define problems collect data establish facts and draw valid conclusions.
Must have ability to critically think through complex situations and make determinations based on presented data.
Computer Skills:
Typing at least 60 words per minute
Proficient in Microsoft Office products including Excel Word PowerPoint
Capacity to learn other relevant systems and hospital medical records
Knowledge of database management

Additional Responsibilities:
Demonstrates a commitment to service organization values and professionalism through appropriate conduct and demeanor at all times.
Maintains confidentiality and protects sensitive data at all times.
Adheres to organizational and department specific safety standards and guidelines.
Works collaboratively and supports efforts of team members.
Demonstrates exceptional customer service and interacts effectively with physicians patients residents visitors staff and the broader health care community.

UofL Health Core Expectation:
At UofL Health we expect all our employees to live the values of honesty integrity and compassion and demonstrate these values in their interactions with others and as they deliver excellent patient care by:
Honoring and caring for the dignity of all persons in mind body and spirit
Ensuring the highest quality of care for those we serve
Working together as a team to achieve our goals
Improving continuously by listening and asking for and responding to feedback
Seeking new and better ways to meet the needs of those we serve
Using our resources wisely
Understanding how each of our roles contributes to the success of UofL Health