at Christiana Care Health System in Wilmington, Delaware, United States
Job Details
PRIMARY FUNCTION:
To assist patients and families to identify social, emotional, and environmental needs and to connect them with available resources/ services through the provision of a full spectrum of discharge planning and social work services.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
Works with the patient, family, and other members of the team to formulate a care plan that provides the client services in the appropriate setting. Gathers and assesses information regarding the client's physical needs, mental status, support system, financial resources, and available community and governmental resources. Employs assessment skills to develop a comprehensive case management plan that will address the needs identified.
Determines specific objectives, goals, and measures that are designed to meet the client's needs that have been identified through assessment. The plan will be action- oriented and time-specific including collaboration with
community services. Maintains contact with the client's support services and insurance to ensure the most cost-effective plan of care is being carried out and appropriate service providers are being utilized.
Provides information about resources and options available in the community and coordinates service delivery.
Interprets patient/family needs and provides information concerning the availability and limitations of resources.
Educates and addresses concerns with service delivery including service gaps and access issues. Implements care management plan through service referral and coordination activities. The Social Worker always assures that the patient is given the choice regarding agencies and services.
As part of the care management plan development process, collaborates with other healthcare and community service professionals.
Screens high-risk patients and consults with community and healthcare agencies regarding potential care planning problems identified as a result of this process. Interviews and assesses referred and high-risk patients to determine the need and desire for social work services.
Provides information based on current knowledge, to provide psychosocial support and assist the client in coping with their healthcare issues to improve their overall health care management.
Provides specific information on how to communicate with physicians and other healthcare staff to better utilize medical resources and increase understanding of the disease process.
The Social Worker will organize, secure, integrate and modify the resources necessary to meet the goals stated in the care plan. The Social Worker will monitor patient care
across the continuum through follow-up with clients, families, and community/ healthcare services.
Educates the client and their support system regarding various symptoms and consequences related to specific diseases, conditions and needs. This information will also include specifics regarding methods of professional intervention and description of the process of social work intervention in a medical setting and with Social Determinants of Health.
Represents the client by intervening, negotiating and promoting their concerns. Problems requiring advocacy may include individual and class inequities or inadequate and non-existent healthcare and/or community resources, i.e., insurance benefits, housing, etc.
Functions as consultant/advisor to program administration, utilization review, public and private insurance programs when care planning or resource issues occur. Keeps administration informed of changes in community, state, and federal policies that impact available resources.
Maintains pertinent and timely documentation in client's medical records and departmental records.
Accurately maintains required departmental statistical data.
Collects and maintains specific information required for performance improvement indicators and research projects as required.
Performs client evaluations and histories. Provides psychosocial support through individual or family counseling, as needs dictate. Continuously reviews service area for needs and opportunities.
Represents ChristianaCare, when requested, through participation on committees, court hearings, referrals to community agencies, etc.
Attends regularly scheduled staff meetings, i.e., team, divisional, or center-wide as required.
Participates in professional activities to support social... For full info follow application link.
Christiana Care Health System is an equal opportunity employer, firmly committed to prohibiting discrimination, whose staff is reflective of its community, and considers qualified applicants for open positions without regard to race, color, sex, religion, national origin, sexual orientation, genetic information, gender identity or expression, age, veteran status, disability, pregnancy, citizenship status, or any other characteristic protected under applicable federal, state, or local law.
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