Social Worker/Patient Enrichment Specialist

Principle Functions:

The incumbent offers short term therapeutic counseling and crisis intervention to patients and families with psychosocial needs, and coordinates and facilitates the development of a discharge plan of care for high-risk patient populations which includes accountability for the complex discharge process.

This position ensures the experience of care for the patient and family is exceptional. Accountable for multiple performance and utilization risk components such as: (1) patient flow and throughput, (2) quality initiatives, (3) facilitating discharge planning, (4) coordination of care, (5) care transitions, (6) psychosocial support, (7) supporting clinical cost reduction, (8) therapeutic supports via group and individual therapies.

Partners with and supports providers in all aspects of patient care and care coordination and engages the patient and family in the plan of care. Must diligently communicate and collaborate with all members of the health care team to facilitate the episode of care so the patient receives services in a safe and timely manner, and the patient and family are provided all necessary resources and education. Always displays a high level of professionalism and engages leadership in problem solving as necessary

Duties and Responsibilities:

• Conducts psychosocial assessments to document history and identify preliminary issues for treatment focus by interviewing the patient and their family members. Psychosocials must be completed within 72 hours of admission.

• Communicates with providers to report patient progress, needs, concerns, and potential and actual problems.

• Works closely with all members of the health care team in development of the Master Treatment Plan, based on the psychosocial assessment and accepted social work interventions. The Master Treatment Plan is to be completed within 72 hours of admission.

• There is to be an Update to the Master Treatment Plan within 7 days of the completion of the Master Treatment Plan. This is to list progress towards goals listed in the Master Treatment Plan.

• Provides group and family process-oriented therapies as well as conducts educational and other didactic groups for patients and family members using various professional treatment modalities. Provision of these services includes the prompt completion of ongoing progress notes.

• Provides social work services including short-term individual counseling, community resource planning, and crisis intervention.

• Social Worker will be cross trained to help support the other social work roles on the team.

• Develops and coordinates an individualized discharge plan for the patient by utilizing treatment team and chart information to determine the patient's aftercare needs.

• Attends regular treatment team meetings to provide social work perspective to total case management of the patient by reading and discussing written progress notes from charts and communicating any state or local agency legal requirement for case management with the interdisciplinary team.

• Develops and maintains thorough knowledge of referral resources throughout the service area.

• Acts as resource person for family members, patients and other members of the health care team, providing in-service education and consultation in understanding the social and emotional factors related to health problems.

• Maintains up-to-date knowledge of Medicare, Medicaid, and other third party reimbursement sources, in conjunction with the Utilization Review team.

• Maintains accurate and timely records, including clinical and progress notes, according to department policy.

• Maintains up-to-date knowledge of field by participating in continuing education activities.

• Provides positive customer relations in dealing with patients, families, physicians, fellow department employees, other hospital departments, referral resources, service agencies, and others.

• Will provide updated patient information, in person or by telephone, a minimum of two times per week to Guardian/POA/Legal Rep or other identified family contact to each patient.

• Will provide updated patient information a minimum of two times per week to each patient’s referring/discharging facility.

• Maintains a professional approach with confidentiality. Assures protection and privacy of health information as attained through written, electronic, or oral disclosures.

• Displays concern and initiative. Is resourceful and calm in emergencies.

• Is prompt and efficient with minimal absences.

• Cooperates and maintains good rapport with nursing staff, medical staff, other departments, and visitors.

• Seeks guidance and remains knowledgeable of, and complies with, all applicable federal and state laws, as well as hospital polices that apply to assigned duties.

• Complies with hospital expectations regarding ethical behavior and standards of conduct.

• Complies with federal and hospital requirements in the areas of protected health information and patient privacy.

• Will conduct all other duties, as assigned.

Patient Enrichment Specialist- Duties and Responsibilities:

Provide an activities program daily including evenings and weekends.

• Provide a plan of activities appropriate to the needs of the patients that includes, but is not limited to:
  • Group social activities.

  • Indoor structured exercise activities

  • Spiritual programs and accommodations to meet worship needs

  • Working with patient to pick activities of interest

  • Creative activities such as arts, crafts, music, drama, educational programs

  • Promotion of facility engagement with peers

• Assure that at least thirty (30) minutes of activities are slotted, at least 4 times per day, per each patient

• Prepare a monthly calendar of activities written in large print and posted in a prominent location that is visible to patients on the milieu, collaborating with nursing, techs, and social workers.

• Assess resident needs and develop resident activities goals for the written care plan, with support of social workers.

• Encourage resident participation in activities and document outcomes.

• Review goals and progress notes.

• Properly document reports and progress notes.

• Participate in treatment team, to provide clinical insight into patient care and facilitate discharge planning

• Complete the patient advocate document for new patients and update patient boards in patient rooms

Obtain necessary equipment and supplies and provide for their accessibility through organized storage.

A. Participate with the CEO and Corporate Activities Director in developing a budget.

Contribute to facility efforts to maintain and /or improve quality of care through participation

in the following:

A. Attend Treatment Team Meetings

B. Serve as a member of the Employee Morale Committee.

C. Attend Department Head Meetings.

E. Server as a member of the Weight Management Committee.

F. Attend mandatory in-services.

Requirements

Education: Master’s degree in Social Work, Master’s Degree in Counseling or Related Field.

Experience: Prefer 3-5 years relevant health care and mental health experience

Prefer discharge planning experience
Prefer individual therapy, group therapies or family therapies experience

Prefer certified activities therapist or Certified Therapeutic Recreation Specialist (CTRS)

Licensure: Preferred Licensed Clinical Social Worker or Licensed Mental Health Counselor in State of Indiana

Skills: Requires knowledge of the impact of the disease process and of human behavior to provide psychosocial assessments; short-term therapeutic counseling; and crisis intervention to patients; families; and staff. Requires strong clinical assessment; planning; and goal development skills. Requires the ability to communicate and resolve conflict with physicians, other health care team members, community agencies, clients and families with diverse opinions, values and religious/cultural ideas. Requires knowledge of community resources and entitlement programs. Requires knowledge of state and county adult protective legal mandates. Requires knowledge of the principles of growth and development over the life span. Requires strong communication skills in giving and receiving information; providing counseling; and developing positive helping relationships with patients and families; physicians; and other members of the health team.

AHCH123