Psychosocial Assessment and Intervention: Meets directly with patient and family to perform a comprehensive assessment including social, emotional, cultural, mental status, environmental and financial circumstances in conjunction with interdisciplinary assessment of the patient.
Recommends a plan of intervention based on patient needs, preference and mutually established goals.
Performs assessments of the physical environment and adequacy of support systems for outpatients to prevent a crisis and/or hospitalization.
Manages Discharge Planning through Placement Coordination, Resource Utilization, and Coordination of Skilled Home Health Care.
Actively participates in the stages of discharge planning and ensures that the plan of care is coordinated, facilitated and effectively communicated to the physicians, healthcare team, patient and family.
Provide initial screening for all new patients to assure medical necessity, source of funding, and likelihood of needing Social Work and/or discharge planning services.
Serves as the point person for the plan of care as it applies to discharge planning needs through facilitation of direct and continuous communication and collaborative decision making, including participation in multidisciplinary rounds and case conferences and other collaborative forums.
Coordinates action plans when barriers are present to facilitate resolution.
Coordinates discharge planning to ensure a timely discharge through early identification, assessment and intervention for post hospital care needs.
Meets directly with patient and family to assess needs, preferences and develop appropriate plan that involves home health care services in collaboration with the physician.
Ensures and maintains plan consensus from patient and family, physician and payer.
Timely discharge is facilitated through early identification, ongoing assessment and intervention for post hospital care needs.
Collaborates and communicates with multidisciplinary team in all phases of discharge planning, ensures and maintains plan consensus from patient and family, physician, and payer as indicated.
Proactively identifies and resolves delays and obstacles to discharge.
Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues and system problems.
Seeks consultation from and makes referrals to appropriate disciplines and departments as required to expedite discharge plan.
Demonstrates knowledge of community resources and an ability to connect patients and families with these resources
Acts as an advocate on behalf of the patient who requires assistance to gain access to needed information, resources, or services.
Facilitates review of high risk cases by Office of General Counsel, Risk Management and informs appropriate members of the healthcare team as to interventions needed.
Coordinates interventions in collaboration with healthcare team and ensures that interventions are successful.
Provides patient and family education that promotes wellness and increases knowledge of the
Benefits
Health insuranceVision insurancePaid time off
Additional Information
The Social Worker LSW reflects the mission, vision, and values of NM, adheres to the organization's Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
Northwesternmedicine · Chicago, IL