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The Caseworker plays an important role in the delivery of services to patients and their families, participating as a member of the multi-disciplinary care team to assist in the development of or implementation of treatment and discharge plans. The Caseworker may provide crisis intervention to patients and families in the hospitals’ medical/surgical units and Emergency Dept. The Caseworker serves as a patient advocate and coordinator of recommended social work services, assisting the patient to achieve their goals. Collaborates with clinical care teams, conducts situational analysis and provides assistance and support to improve patients’ medically related social and psychological conditions. Meets with patients, families, and/or support system on a regular basis to assess circumstances and needs. Acts as a liaison between patients and hospital and post-hospital service providers. Functions as part of interdisciplinary care team and is able to function autonomously while meeting needs of patients, department, and staff. Strict adherence to HIPAA regulations is required. Actively participates in Quality Improvement Initiatives within the department, hospital and/or community. Supervision is provided by LMSW and/or LCSW.

EDUCATION AND EXPERIENCE REQUIREMENT(S):

+ Bachelor’s degree in Social Work, Sociology, Psychology or related field required. MSW preferred.

+ One year experience in a medical, psychiatric, or health care setting required. I

+ Intake and Discharge planning experience preferred.

+ Working knowledge of community resources, including but not limited to: Domestic Violence, CPS, APS, caregiver support, substance use disorders and behavioral health services, homelessness, entitlements.

+ Knowledge of issues and regulations related to end of life care/advance directives/voluntary and involuntary treatment for special populations (developmentally disabled, mentally ill, nursing home residents.

+ Demonstrated ability to communicate effectively both written and verbally.

+ Ability to effectively utilize multiple EMR platforms.

PHYSICAL REQUIREMENTS:

The position requires the individual to be able to move easily into and out of various buildings, and to climb stairs. Should be able to push/pull 25 lb., lift/move 15 lb. from floor to table, be able to perform moderately difficult manual manipulations such as using a key board, writing and filing for extended periods of time, must be able to perform tasks which require hand-eye coordination such as data entry, typing and using photo copiers. Mobility requirements may include the ability to sit at a computer terminal or work station for a prolonged period of time in addition to being able to squat, stand and walk for a reasonable length of time and distance..

PRIMARY RESPONSIBILITIES OF THE POSITION:

+ Assists social worker/licensed staff with the assessment of patients and the development and implementation of the treatment and discharge plan.

+ Screens and accepts appropriate referrals per established department process.

+ Obtains and documents, in accordance with department standards, demographic data and social history, makes informal observations, and screens patients to identify needs and determine the presence of potential barriers to discharge which may negatively impact optimal patient functioning, including but not limited to social determinants of health

+ (i.e.: unstable housing/homelessness; unemployment; financial issues; insurance issues; access to health care, transportation, food and medicine; limited health literacy; behavioral health co-morbidities).

+ May interview family and other collateral contacts to gather information and identify patient support system.

+ Meets with patients to listen to concerns, discuss goals and evoke motivation for change, engage in problem solving.

+ Collaborates with clinical care teams to review for medical necessity and medical appropriateness of mental health and chemical dependency services available to patients and to assist in the development of after-care and follow-up plans, in accordance with mental health parity guidelines.

+ Assists in identification of vulnerable populations to ensure appropriate and safe care in accordance with hospital policy and regulatory requirements.

+ Makes referrals to inpatient and outpatient treatment programs

+ Identifies high risk patients/frequent readmissions using established hospital and organization criteria.

+ Acts as a patient advocate within the interdisciplinary team

+ Functions as member of the interdisciplinary care team

+ Participates constructively in interdisciplinary rounds, unit care conferences, complex care committee, and other patient centered care teams as necessary.

+ Assists patient focused care teams with arranging and conducting patient/family meetings.

+ Serves as resource to patient focused care teams regarding resources available in patient’s community of choice for post-acute care.

+ Serves as resource to patient focused care teams regarding issues and regulations related to end of life care/advance directives/voluntary and involuntary treatment for special populations (developmentally disabled, mentally ill, nursing home residents)

+ In collaboration with care team, makes referrals and revises after care plan as patient’s needs change.

+ Provides Care Coordination to reduce fragmentation of care.

+ Makes timely referrals to inpatient and outpatient treatment programs and community services (i.e.: Capital Region Health Connections Health Home, P.S.C.C., county or private mental health treatment settings, SPARC services, Dept. of Social Services, housing/shelter services, home care agencies, domestic violence services, Primary Care Case Managers, etc.).

+ Coordinates timely transfers to appropriate levels of care as indicated by clinical needs and utilization criteria, in accordance with interdisciplinary team assessments, hospital policy and applicable state and federal guidelines and regulations. (i.e.: inpatient psychiatric setting, crisis evaluation, nursing home, home with supports, etc.)

+ Assists with facilitation of patient care transitions across the care continuum within SPHP and the patient’s community of choice, and to least restrictive most independent environment possible.

+ Develops and maintain knowledge of and understanding of Hospital, Organization, and community resources and facilitates us of the most appropriate level of care to conserve patient, hospital, and payer resources.

+ Documents referral information in a timely manner in accordance with department standards, including referral date/time, contact name/number/fax, response of referral and patient interaction/awareness of referral outcome.

+ The Emergency Dept. Caseworker will perform the duties as outline above. Additionally they might:

+ Identify High Utilizer patients via monitoring of ED Tracker, communication with C3’s, providers, nurses, and ancillary ED staff.

+ Assist with disposition based on safety related to presenting issues, i(.e: CPS, APS, Detox, Domestic Violence, Caregiver Burden, Mental Health/Substance Use Disorder, and homelessness); in accordance with hospital, SPHP, and regulatory guidelines; this may include pre-screening and referring to in-hospital Detox Service for determination of inpatient or outpatient treatment.

+ May take lead as representative of care coordination department in identification of vulnerable populations to ensure appropriate and safe care of patient in accordance with hospital policy and regulatory requirements. (ie: Contact after-hours on-call representatives of APS, CPS, and other agencies to initiate reports)

+ Meet with families/support system to provide bereavement support.

+ Meet with patient/family caregivers to offer support and resources to diminish caregiver burnout.

+ Advocate for and facilitate discharge or transfer to appropriate level of care, i.e.: psychiatric facility, crisis evaluation center, housing, shelter, care facility, home with services and supports.

Ellis Medicine is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, creed, color, religion, sex/gender, age, national origin, disability, genetic information, predisposition or carrier status, military or veteran status, prior arrest, or conviction record, marital or familial status, sexual orientation, transgender status, gender identity, gender expression, reproductive health decisions, or domestic violence victim status.

Salary Range: $22.08-32.31 /hour Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.