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Employment Type:

Full time

Shift:

Day Shift

Description:

To provide professional discharge planning services through assessments, and coordination of

post-hospital care needs to patients and their families. Provides resources and choices to families

to effectively link them to the needed level of emotional, medical and spiritual care.

This role will receive referrals for individuals from at-risk populations from interdisciplinary

team members (including physicians, Care Managers, staff nurses and other members of the

care team). Participates as an active member of multi-disciplinary team.

II. Position Responsibilities:

No.

Percent of Time

Essential Duty

Job Duties

1

55%

Yes

Complex Discharge Planning based on assessment of patient and family

needs, preferences and available resources in order to ensure a timely

discharge and to provide appropriate linkage with post-discharge care

providers( i.e. New/Resumptions SNF, LTAC, Rehab, Dialysis, Hospice,

DME and Home Health etc.)

1.Develops discharge plan in direct consultation with patient, family, physician, and

health care team. Deals with families exhibiting complex family dynamics that

impact directly on patient care and discharge.

2.Manages complex cases/situations and intervenes with and advocates for patients

and families as plan of care and discharge plan are developed.

3.Educates patients and families regarding appropriate resources, access to services

and third party requirements, and makes appropriate and timely referrals to

address post-acute discharge needs.

4.Provides consultation to Case Managers when coordination with significant or

intensive community resources is necessary to achieve desired treatment outcomes

5.Uses knowledge of insurance benefits and coverage guidelines to maximize

appropriate utilization of resources.

6. Maintains effective communication and working relationships with members of

the interdisciplinary team.

7.Attends care conferences/unit huddles or other care planning meetings as per

department policy.

8.Partners with external agencies and facilities to provide continuity of care for

patients and families.

9.Documents all interventions and discharge plans to provide the health care team

with accurate and up-to-date information regarding development/progress of the

discharge plan and psychosocial interventions with responses.

B. Completion of an assessment/history on all identified patients within

appropriate time frames.

1.Interviews patient and significant others to assess patient’s psychosocial situation.

2.Identifies patient and family preferences, needs and strengths, to foster for the

patient and family empowerment and independence to make autonomous health

care decisions and access needed services within the health care system.

35%

C. Psychosocial Assessment and Interventions on the basis of preliminary risk

screening, assesses patients 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. Supportive counseling

and clinical Social Work intervention for patients and families in acute

emotional distress.

1.Counsels patients and families regarding issues of loss, disability, separation,

financial impact, and traumatic life style changes. Coaches families in developing

coping mechanisms to support adaptation to changes.

2.Counsels and assists patients and families regarding Advanced Directives, end of

life issues, and ethical issues that may arise.

3.Interacts with appropriate agencies on issues of suspected abuse and neglect,

domestic violence, guardianship, and other social/legal matters. Utilizes crisis intervention techniques when indicated.

5.Provides referrals to community-based support resources as appropriate.

6. Manages the progression of patients stay with the goal of optimizing the LOS and

ensuring appropriateness of assigned Level of Care.

2.Manages the patients care across the continuum to decrease unnecessary

readmissions.

3.Manages and coordinates patient care within an ACO environment to help

facilitate patient outcomes through in network care coordination.

D. . Engages in Performance Improvement and patient safety initiatives.

1.Identifies and communicates quality, risk, and patient safety issues to Care

Management or other appropriate leadership.

2.Accepts responsibility by participating in staff, department, or Organizational

process improvement and safety initiatives.

10%

E. Professional Development: Maintenance of professional standards and responsibilities for his/her own professional practice according to accreditation, hospital, system, state and NASW Standards and Code of Ethics.

1.Completes all required continuing education to maintain licensure and increase

knowledge within area of practice specialty.

2.Completes and utilizes all annual safety and competency training.

3.Maintains up-to-date knowledge of community resources, legislation, and

regulations impacting health care delivery and educating patients and families on

these issues as appropriate

Freedom of Action:

Supervisory Responsibility:

+ **Staff:** N/A - position does not supervise staff

+ **Functional:** N/A - no functional supervisory responsibilities

Safety Accountabilities:

+ Loyola is committed to providing care that is safe. It is expected that all Loyola employees will perform their job function in a professional and competent manner that constantly seeks to reduce the risk of harm to patients, families and co-workers.

Quality Improvement Accountabilities:

+ Loyola is committed to the continuous improvement of the services it provides to its patients and their families. All Loyola employees are expected to participate in quality improvement activities.

Service Excellence Accountabilities:

+ Responsible for consistently demonstrating our values of Care, Concern, Respect and Cooperation through teamwork and effective communication in an effort to prevent and solve problems and to achieve quality outcomes, patient safety, customer satisfaction and a safe environment.

+ Responsible for developing and maintaining an environment of service excellence as outlined in the Service Excellence standards.

**III. Position Requirements** :

Minimum Education:

+ **Required:** Masters Degree of Social Work from an accredited school

+ **Preferred:** Masters of Social Work with Clinical Licensure

+ **Specify Degree(s):** N/A

+ **Residency:** N/A

Minimum Experience:

+ **Required:** 1-2 years of previous job-related experience

+ **Preferred:** N/A

**Managerial Experience:** N/A

Licensure/Certifications:

+ **Required:** LSW,

+ **Preferred:** LSW, LCSW or ACM

+ **Other:** N/A

Computer Skills:

Required:

+ Microsoft Excel

+ Microsoft Outlook

+ Microsoft Power Point

+ Microsoft Word

+ **Preferred:**

+ EPIC, Allscripts

+ **Other:** .

**Typing Words Per Minute:** N/A

Required Skills:

+ Ability to communicate verbally

+ Effective time management, organization and documentation skills necessary

+ Ability to deal calmly and courteously with people

+ Ability to manage crisis situations

+ Resiliency and flexibility to effectively work within a constantly changing health-care environment

+ Fast paced work environment with

+ Ability to maintain accuracy and consistency

+ Ability to maintain office files and follow standard office procedures

+ Ability to work as an effective team member

+ **Other:** N/A

Personal Relationships:

+ Routine job with interpersonal contact

Internal Contacts:

+ Within Department

+ Physicians

External Contacts:

+ Other healthcare agencies

+ Post-acute nursing facilities/resources

Working Conditions:

+ Normal light, heat, air and space in work environment

+ Work takes place on hospital unit or clinical setting

Physical Demands:

+ **Occasionally:**

+ Pushing/Pulling

+ **Frequently:**

+ Standing

+ Sitting

+ Reaching with Arms

+ Finger/Hand Dexterity

+ Talking

+ Hearing

+ Seeing

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 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.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran