The Clinical Social Worker functions as a multidisciplinary team member who provides direct clinical services and interventions to patients, families and significant others from newborn through the end of life. The social worker assists patients and families with disabilities, adjustment to illness, personal, financial and environmental difficulties which may predispose illness and interfere with obtaining an optimal level of medical care and quality of life. They provide comfort, support, emotional counseling, short-term triage, and crisis intervention to patients and their families. When needed, assists in identifying patients who will require discharge planning services. Provides consultation to staff and coordinates with community-based providers as required and ensures referrals to post-hospital care and services.
Master’s Degree in Social Work from an accredited school of Social Work or equivalent.
Documentation of ongoing continuous education specific to Social Work and Palliative Care.
Licensure / Certification
Licensed Masters Social Worker in the State of Michigan
Special Skill / Aptitudes
Must possess high level of analytical ability necessary to identify and plan for the resolution of difficult psychosocial illness related problems
Must possess a high level of interpersonal skills necessary to provide counseling to patients and their families on psychosocial illness and related problems.
Must possess leadership and group work ability necessary to function in a shared governance department structure.
Must have good knowledge of the principles and practices of social work. Will be expected to utilize a variety of highly developed skills in individual and/or group methods.
Demonstrated skill in patient assessment pertinent to the age group(s) served. Knowledge of community
resources, and skill in managing referrals. Demonstrate ability to practice social work within a team environment.
Possess an advanced knowledge of the impact of illness on to patient and family as well as an understanding of age specific needs and cultural differences.
Excellent customer service orientation skills necessary in order to deal effectively with various levels of hospital personnel, outside customers and community groups.
2 Years of Clinical Experience
Work requires some knowledge of health care, community resources, illness and disease, and medical terminology associated with the services on the patient care unit(s).
Duties / Responsibilities
1 Collaborates with the multidisciplinary team by providing a comprehensive clinical , social assessment in order to develop and implement the most appropriate plan of care of the newborn through the end of life.
2 Assesses, directs and provides referral information to patients and their families to community agencies/facilities for short and long term assistance. In addition, maintains a strong and ongoing working relationship with these agencies.
3 Implements discharge plans on complex discharges based upon a thorough needs assessment in collaboration with the Patient Logistics Practitioner (PLP).
4 Coordination of durable medical equipment (DME) for complex discharges
5 Provides and documents in the electronic medical record consultative clinical / social services delivered to each patient. Ensures documentation of assessment, plan of care and follow up are accurately completed and demonstrate ongoing support to the care of the patient during their hospital admission thru discharge transitions.
6 Assumes responsibility for welfare of patients through the initiation of child abuse referrals, adult protective services referrals, nursing home abuse, domestic violence referrals and guardianship petitions. Performs the assessment, initiates referrals and appears in court as subpoenaed by the system.
7 Works collaboratively with other members of the health care team, including medical staff, patient logistic practitioners, pain and palliative care members, Hospice and other community agencies to provide support and ongoing planning for psychosocial aspects of care throughout the stay and discharge transitions.
8 Develops and conducts educational in-services related to a patients psychosocial care and/or illness, as well as well as informing healthcare care team members of current community resources that are available to patients.
9 Formulates discharge plans by collaborating with the patient/family, members of the healthcare team (i.e PLP[Patient Logistics Practitioner], medical staff, nursing staff, other) and outside agencies/facilities. Develops and coordinates discharge plans for complex cases such as patients with difficult family dynamics, patients facing end of life issues, placements to extended care facility (ECF), acute long term care facility, dialysis, arranging home healthcare and DME.
10 Assessing financial status to determine eligibility
Demonstrates and actively promotes an understanding and commitment to the mission of St. Joseph Mercy Oakland through performing behaviors consistent with the Trinity Health Values.
Maintains a working knowledge of applicable Federal, State, and Local laws and regulations, the Trinity
Health Organizational Integrity Program, including the Standards of Conduct, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behaviors.
Supports and conducts one’s self in a manner consistent with customer service expectations.
In accordance with unit or departmental practice, determines that appropriate charges have been entered for the correct patient, encounter, date/time of service, with any required modifiers. Make corrections as needed per charge capture policy/practice.
In accordance with unit or departmental practice, actively participates in on-going education and communication regarding revenue management.
In accordance with unit or departmental practice, assists with tracking and monitoring of equipment assigned to the unit. Requests services for maintaining equipment as needed.
In accordance with unit or departmental practice, proficient with the electronic health records for documentation, assessment, and care management, performing these activities concurrently with provision of care throughout the shift.
Trinity Health’s Commitment to Diversity and Inclusion
Trinity Health employs about 133,000 colleagues at dozens of hospitals and hundreds of health centers in 22 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Trinity Health’s dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.
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