Social Worker II - Continuum of Care - Part-Time

Work Shift Evening Shift Scheduled Weekly Hours 20 Summary This position supports Mercy's philosophy of patient centered care by providing our patients and their families support and resources to manage the many psychosocial aspects of illness. A social worker works with patients and their identified support system to access the needed resources to cope with illness and life changes triggered by illness.

This may include referral to needed community resources, assistance in applying for financial assistance programs or the provision of supportive counseling in coping with illness and the life changes resulting from illness. Job Description Job Duties/Essential Functions Job Duties Ensure that all accurate and clinically relevant information is communicated with patients, their families and co-workers at hand offs and other times as needed.

Take all measures necessary to ensure that the appropriate and involved parties have communicated necessary information in order to allow for the best possible patient outcome. Assesses patient/family social, emotional and economic factors through initial admission assessment and ongoing evaluation/assessment and reassessment. Serves as a resource to the patient/family assisting them with accessing appropriate resources to address concerns/needs and removing barriers to care.

Actively participates in multidisciplinary team meetings advocating for the patient and educating team regarding psychosocial issues impacting ability to cope with health care concerns and safely preparing for care transitions/discharge planning. Documents in the medical record accurately, timely and in accordance with professional and department-specific standards. Demonstrates an understanding and an ability to work effectively with the community professionals/agencies providing patient services throughout the continuum of care.

Maintains current knowledge of community and other resource networks for planning/provision to meet patients' needs. Demonstrates skills in advocacy for all populations served. Provides counseling and ongoing therapeutic relationship to assist patients/families in coping with the effect of serious illness, death and grief and/or mental illness Provides education and consultation to health care staff on patient behaviors, communication, conflict resolution, confidentiality and professional boundaries Follows Mercy's safety guidelines, carries out job-specific safety duties and responsibilities, and promptly reports any unsafe conditions, situations, incidents and injuries.

Department Specific Duties Care Coordination (Inpatient, Birthplace, and ED Social Worker II) Specialized knowledge of acute care medicine and hospital operations Expertise in Medicare/CMS discharge planning requirements and accreditation expectations. Direct Responsibility for safe and timely discharge planning that affects patient outcomes and organizational finances. Daily collaboration with physicians and interdisciplinary teams in a fast-paced acute care environment.

Management of complex placement barriers, insurance issues, guardianship, advance directives, and post-acute services. Influence on length of stay, avoidable days, readmissions, patient flow, and bed capacity. Assisting acutely ill patient with multiple medical, psychosocial, and financial needs. Conduct comprehensive chart reviews for assigned patients, including medical history, IV antibiotic needs, infectious disease involvement, oxygen requirements, and referral sources to support discharge planning.

Complete initial case management and Social Determinants of Health (SDOH). Assists in transfer, change in level of care and discharge planning by implementing and coordinating services required for discharge. Demonstrates an ability to de-escalate patient situation utilizing CPI techniques. Assists with bereavement support and outreach activities, such as Caregivers Center, etc. Assists with determining patient's appropriateness for hospice serv