Position Summary:

 Social Workers in hospitals provide frontline services to patients with conditions spanning the entire healthcare continuum. Working in concert with the multidisciplinary team, SWs sensitize providers to the social and emotional aspects of a patient’s illness. They use their case management skills to help patients and families address the social, financial, and psychological issues related to their overall health. The SW assesses the patient’s transitional care needs, performs psycho-social assessments and discharge planning relevant to the patient’s medical treatment.

Hospital discharge planning is a process that involves determining the appropriate post-hospital discharge destination: identifying what the patient requires and beginning the process of meeting the patient’s identified post-discharge needs (482.43 CoP: Discharge Planning).

Essential Duties and Responsibilities:

1. Performs psychosocial assessments and transitional care screens on all patients as per department and hospital policy.

1. Participates in care planning based on age specific needs.

1. Initiates discharge planning process within first 24 hours of admission or next business day.

1. Monitors patient's length of stay in coordination with the Nurse Case Managers.  Addresses barriers to discharge and discusses with the multidisciplinary team.

1. Serves as contact resource fo patients, families and surrogates and meets family and/or significant others to discuss patient’s post-acute treatment needs and discharge planning according to HIPPA and hospital privacy guidelines.

1. Educating patients/families on the levels of health care (i.e. acute, sub-acute, homecare, LTACH, hospice etc.), community resources and goals of care. Services may also include non-traditional health care (i.e. transportation, MOWs, homemaker services etc). Provides the patient/family a list of facilities and services in the geographically area requested by the patient.

1. Arranges essential durable medical equipment as ordered by the physician (i.e. bed, wheel chair, infusion, enteral feedings etc).

1. Sends appropriate medical information to providers as per patient preference prior to discharge in accordance with HIPPA and hospital policy.

1. Understands and educates patient/family/staff that patients have the right to participate in the development and implementation of their post-acute discharge care.

1. Coordinates patient/family conferences to discuss treatment plan, goals of care and post-acute needs.

1. Provides consultation to staff regarding psychosocial, bioethical issues and discharge barriers as well as possible community resources.

1.  Attends weekly staffing rounds and provides input as appropriate.

1. Assures appropriate communication with referral sources during inpatient treatment, if indicated.

1. Assists with setting up Tele-Psych evaluations as requested by the physicians.

    15. Works with psyche intake units to promote a safe transfer to inpatient psyche as per physician referral.

Other Responsibilities:

1.            Adheres to downtime procedures.

2.            Adheres to established departmental policies, procedures, and objectives.

3.            Performs both essential and non-essential job functions in a safe manner as identified by West Suburban Medical Center.

4.            Demonstrates an understanding of and models the mission and core values of West Suburban Medical Center through behavior and attitude.

5.            Enhances professional growth and development by accessing educational programs, job related literature, in-service meetings, and workshops/seminars.

6.            Performs other related duties as assigned.