Reports to the Director of Operations. Provides short-term intervention for discharge planning services and psycho-social support. Uses assessment tools to identify post hospital needs for continuity of care and to ensure a safe discharge plan. Knowledgeable of community resources and programs which assist patients with psycho-social, financial and legal needs.MISSION, VALUES and SERVICE GOALS
MISSION: We deliver outstanding care, inspire health, and connect with heart.
VALUES: Trust. Respect. Integrity. Compassion.
SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.
Actively coordinates and facilitates the development of a continuity of care plan by:
Initiating screening of patients based on Social Service protocol.
Reviewing patients' medical record to obtain and prioritize pertinent data necessary for a comprehensive evaluation of the patient's ongoing needs.
Interviewing the patient and/or family in order to obtain pertinent medical, financial, social and/or psychological data needed to assess patient status and potential needs.
Collaborating with appropriate medical, nursing and multi-disciplinary staff to ensure coordination of care within the healthcare team.
Developing a discharge plan based on consultation with physician(s), the multi-disciplinary healthcare team and in consideration of patient's insurance provider and benefits.
Involving the patient and family in care planning and treatment decisions.
Consistently documenting assessments, interventions and outcomes in order to maintain appropriate case records and statistics in accordance with the hospital's requirements and outside agency standards.
Prioritizing referrals in relationship to workload received from a variety of healthcare team members.
Provides short-term intervention to patients/families regarding psycho-social, financial and legal needs:
Referring patients and families to community agencies, resources and other providers appropriate to the patient's specific needs.
Acting as an advocate for patients.
Collaborating with Utilization Review and other departments (Eligibility Specialists, Financial Counselors) to share accurate and timely information about the patient's status.
Assisting with identification of patients/families who may qualify for federal, state or local programs.
Consults with Manager/Director regarding barriers to discharge.
Participates in appropriate community activities related to social services functions by:
Providing consultation and education to agencies and groups when requested.
Developing and maintaining collaborative working relationships with community providers and agencies.
Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:
Participating in hospital activities and committees when appropriate.
Serving as a resource to the hospital and the community in area(s) of expertise.
Completing other job-related assignments and special projects as directed.
ORGANIZATIONAL RESPONSIBILITIES
Associate complies with the following organizational requirements:
Attends and participates in department meetings and is accountable for all information shared.
Completes mandatory education, annual competencies and department specific education within established timeframes.
Completes annual employee health requirements within established timeframes.
Maintains license/certification, registration in good standing throughout fiscal year.
Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
Adheres to regulatory agency requirements, survey process and compliance.
Complies with established organization and department policies.
Available to work overtime in addition to working additional or other shifts and schedules when required.
Commitment to Beacon's six-point Operating System, referred to as The Beacon Way:
Leverage innovation everywhere.
Cultivate human talent.
Embrace performance improvement.
Build greatness through accountability.
Use information to improve and advance.
Communicate clearly and continuously.
Education and Experience
The knowledge, skills, and abilities as indicated below are normally acquired through the successful completion of a Bachelor's (BSW) or Master's (MSW) of Social Work. A minimum of three to five years of job-related experience is preferred. Candidates are required to have a license or must obtain a license within 3 years of employment.
Knowledge & Skills
Requires assessment and problem solving skills. Also has general understanding of medical conditions.
Requires a thorough knowledge of community agencies, services, entitlement programs and financial resources available on a federal, state and local level to assist patients and families in Indiana and other states.
Requires knowledge of state and local adult and child protective legal mandates.
Requires knowledge of the discharge planning process and understanding of home care, extended care, long term acute care, and other services to ensure a safe transition to another level of care.
The ability to work with acutely ill patients and comfortable with end of life care.
Demonstrates the ability to maintain professional composure under pressure.
Demonstrates the knowledge and skills necessary to provide age-specific care appropriate to the patients served. Also understands and respects cultural, ethnic, religious, and economic differences among patients.
Demonstrates ability to develop and maintain effective and positive working relationships and the ability to be empathic and abide by mutual respect policy.
Demonstrates proficiency in basic computer skills (i.e., data entry and word processing) and related applications; requires ability to access information on the Internet.
Demonstrates the ability to maintain flexibility and a positive attitude.
Demonstrates and maintains ethical conduct and professional judgment, take initiative
and exercise discretion. Also requires a solid understanding of the hospital's policies/practices related to patient confidentiality.
Working Conditions
Works in a high-stress office and patient care environment with rapidly-shifting priorities and competing demands. Also has some contact with patients and family members who are experiencing stressful situations.
May be exposed to bio-hazards.
Ability to work flexible hours.
Physical Demands
Requires the physical ability and stamina (i.e. to walk/stand for prolonged periods of time, push carts/wheelchairs up to 50 pounds, to position/lift patients at a maximum of 35 pounds unassisted, over 35 pounds requires assistance, provide CPR, etc.) to perform the essential functions of the position.