Job Description

Description

Social Work Specialist PT Days

AdventHealth Palm Coast

Location Address:  Palm Coast, FL

Top Reasons to Work at AdventHealth 

Health Insurance Coverage

Faith-based organization

Great benefits such as: Educational Reimbursement

Career growth and advancement potential

Immediate Benefits

Work Hours/Shift:

PT/Days

You Will Be Responsible For:

• Psychosocial Assessment and Interventions

• Assesses patient’s and family’s psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope
• Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability; accesses and mobilizes family/community resources to meet identified needs
• Serves as a resource to provide information and intervention related to treatment decisions and end-of-life issues
• Provides grief counseling and crisis intervention skills
• Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the healthcare system
• Provides de-escalation services for patients as appropriate
• Provide Motivational Interview techniques for patients with substance use and addictive disorders.
• Provides patient/family education, adjustment-to-illness counseling, grief counseling and crisis intervention.  Provides education to patients/families/caregivers regarding resource options and coping with diagnosis, treatment and prognosis.
• Works in collaboration with hospital and community agencies to obtain needed services and resources for patients/families/caregivers.

• Receives referrals for psychosocial complex problems from the health care team.
• Provides assessment and reporting interventions in child abuse/neglect, domestic violence, adult/elderly abuse, child protection and sexual assault, as appropriate
• Provides consult services for patients who may possibly lack decision making capacity.  Follows the guardianship (temporary/ permanent) policies sand procedures and coordinates with Care Management leadership throughout the process
• Provides consult services for foster care and adoptions.
• Assists the health care team in the patient assessments and placements for mental health services.
• Facilitates full team discussion including patient and family when ethical dilemmas arise
• Completes Initial Evaluation for transition of care needs on all identified patients within one calendar day of admission and documents according to policies and procedures. Interviews patient and involved care givers (as permitted by the patient) as well as a review of the current and past inpatient and outpatient medical record in the Initial Evaluation.
• Reviews necessary patient information including labs, medications (Pre and post hospital), History and Physical, Therapy notes, ED notes, test results and progress notes.
• Incorporates the patient/family care goals and preferences as much as possible into the transition of care planning and communicates these goals and preferences to the multidisciplinary team.
• Incorporate clinical, social and financial factors into the transition of care plan.
• Meets with patient/families to discuss realistic and appropriate discharge options and providers of post-hospital care. 
• Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to meet the individual needs of each patient
• Identifies and collaborates with the interdisciplinary team and hospital operations to resolve potential barriers to transition of care plan achievement.
• Collaborates with the multidisciplinary healthcare team daily in   rounds to efficiently communicate and facilitate high quality patient progression of care and transitions plans. 
• Evaluates the potential for readmissions throughout the patient stay through the monitoring of each patient’s readmission risk scores and coordinating readmission mitigation interventions.
• Assures Social Work consults are completed for specialty services related to psychosocial needs, decision making needs for patients who lack capacity, patient/family adjustment needs and psychosocially complex cases.
• Develops discharge plan with appropriate contingency plans throughout the hospital stay to enable adaptation to evolving patient care needs and ensure timely care coordination.
• Escalates issues barriers to appropriate level of Care Management leadership
• Assists with End of Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR.
• Facilitates patient care conferences with multidisciplinary team as needed.
• Establishes and documents, based on the predicted DRG and multidisciplinary team member’s input, Anticipated Date of Transition (ADOT) and destination and updates, as needed.
• Actively participates in daily Multidisciplinary Rounds to review progression of care and discharge plan for all assigned patients
• Proactively identifies patients who no longer meet medical necessity and escalates potential denials, documents avoidable days, and facilitates progression of care.
• Collaborates with Utilization Management staff for collaboration on patient status changes and medical necessity discussions.
• Ensures all patients on assigned unit(s) are moved timely and effectively to appropriate levels of care
• Ensures reassessment of discharge needs provided anytime a patient’s condition changes and/or the circumstances impacting the provision of post-hospital care changes.
• Ensures patient notifications are provided and documented in a timely manner for compliance:  Important Medicare Letters (IML), Medicare Outpatient Observation Notice (MOON), Patient Choice, and Beneficiary Notice Letter (BNL). more