The Clinical Social Worker is responsible for participating in interdisciplinary care of patients and their families with complex medical and social needs. The Social Worker provides supportive counseling, crisis intervention, case management and community resource referrals. S/he functions as a member of a multi-disciplinary team to facilitate the delivery of services to patient and families. The social worker collaborates with the rest of the team to identify, assess, plan, implement, coordinate, monitor and evaluate options and services to meet the complex needs of patients.

This role lends emotional and social support during the active treatment and recovery period. This includes assisting patients in meeting their emotional, psychosocial needs, performing diagnostic assessments, crisis interventions, social and financial concerns, and coordinating a plan of care to address patient/family needs and providing information and referrals as needed. This position in the Palliative Care Clinic and Radiation Oncology Clinic also includes performing short-term individual and family psychotherapy.

This position facilitates support groups and education activities for patients, families and the general public. Provides case management services including referrals to homecare, hospice and supportive care with a multitude of community agencies and other agencies. Assists patients with housing and transportation needs.

Patient Care

• Utilizes knowledge of clinically appropriate treatment theories in the patient and family assessment process.
• Conducts comprehensive individual and family assessments to identify and prioritize needs to be addressed. Performs psychosocial assessments with patient/family involvement, utilizing an interdisciplinary approach.
• Elicit information about patient and family strengths and culture so the plan of care can be individualized. Provide patient and family with assistance to resolve any conflicts or issues they encounter while navigating their healthcare needs.
• Assists in the development of individualized plans of care, including interventions and treatment plans, with clear and measurable goals and objectives. Supports patients and families as they transition through the continuum of care.
• Provides patients and family members appropriate psycho-education based on identified needs. Provides patient and their family with education regarding management of health care needs. Facilitates support groups and preventive care education for patients, families and the community.
• Provides supportive counseling and emotional support to patients and family members. Stabilizes patients who are in crisis. Emotionally supports patient and family during time of loss.
• Participates in quality improvement efforts. Assists with the mitigation of risk for readmission when patients have multiple and complex needs.
• Communicate information clearly and in a manner appropriate to the level of patient and family understanding.
• In the Palliative Care Clinic and Radiation Oncology Clinic, provides psychotherapy for patients/families. Develops individualized family psychosocial plans that are responsive to patient/family concerns, age specific problems, and clinical impressions. In Radiation Oncology Clinic, completes NCCN distress thermometer for all patients.

Coordination of Care

• Establishes rapport with patients, family members and other professionals as the initial step toward partnership in plan of care development.
• Initiates consultations with other health care professionals to promote an interdisciplinary plan of care for complex situations. Functions as a part of the multi-disciplinary team to ensure care and addressing of concerns. Provides consultation to members of the care team in managing complex and/or difficult situations/behaviors.
• Facilitates the implementation of individualized treatment plan as directed by the patient's care team. Acts as a resource to other departments and the public. This includes fielding questions, mentoring, and/or providing educational opportunities.
• Develops and maintains effective working relationships with staff, other departments, system administration/leadership and community organizations to promote positive image, heighten awareness and promote collaboration.

Communication and Documentation

• Solves complex problems by conducting a thorough analysis, brainstorms multiple potential solutions and selects and implements the solution which has the best fit and therefore the greatest likelihood of producing the desired result.
• Communicates and documents assessment, plan of care and/or ongoing needs. Communicates patient and family needs with the primary care team and care coordination.
• Accurately prepares documentation utilizing the electronic medical record. Appropriately document information in patient medical record; maintains timely and accurate documentation of assessments, interventions, EMR entries, and patient responses.
• Revise and update plan of care as the patient's parameters and needs change.

Community Resources and Care Management

• Makes necessary referrals to appropriate members of the healthcare team and/or outside agencies.
• Provides case management and referrals, which can include but is not limited to, homecare, hospice, supportive care and community agencies.
• Assists patients in accessing financial assistance through NAH and community programs.
• Connects patients and family members with community service providers and other community resources. Serve as a liaison for the patient, family, care team and ancillary services.
• Serves as a resource for the available health care resources/agencies that serve special needs patients and children.
• Coordinates care with insurance companies, managed care entities and other community partners.
• Assists patients with housing and transportation needs.
• In the Radiation Oncology Clinic, connects patients with programs provided by the American Cancer Society.

Compliance/Safety

• Responsible for reporting any safety-related incident in a timely fashion through the Midas/RDE tool; attends all safety-related training programs; performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner.
• Stays current and complies with state and federal regulations/statutes and company policies that impact the employee's area of responsibility.
• If required for the position, ensures all certifications and/or licenses are up-to-date and valid prior to expiration dates.
• Completes all company mandatory modules and required job-specific training in the specified time frame.
• Involves law enforcement, Department of Children's Services or Adult Protective Services as appropriate to assist in addressing patient safety issues.
• Collaborates with Compliance department when appropriate.
• Responsible for coordinating complex Guardianship cases.

Education

• Master's Degree in Social Work or Counseling or Clinically Related Behavioral Health Field - Required
• Care Management - Master's Degree in Social Work - Required

Certifications

• LMSW- Preferred
• LCSW- Preferred
• Fingerprint Clearance Card application number- Required upon hire
• Fingerprint Clearance Card- Required within 90 days of hire

Experience

• Minimum 2 years of social worker experience - Required
• Minimum 1 year experience in area of specialty – Preferred
• Medical Social Work – Preferred
• Care Management - Preferred

** Depending on your nursing unit, being “on call” may be required.