The role starts from inpatient engagement with high risk patients prior to discharge to assist in outpatient transitions of care process including scheduling to come to the TCC or other community providers
Performs psychiatric assessment, formulates diagnosis and in consultation with referring physician recommends and completes appropriate disposition. Discusses case with Attending Physician to determine if the patient has been cleared medically and to determine why a consult is requested. Responds in timely manner to request from Emergency Department Physician for psychiatric consultation.
Provides clinical social work services or psychosocial assessments to patients/residents and families, regarding the following common problems: adjustment to instituitional living, financial concerns, family relationships, difficulty understanding / accepting medical / diagnoses / procedures / treatments, changes relating to aging, powerlessness, discharge planning and counseling related to death and dying.
Implement the Plan of Care provisions to meet their needs, which include: social service goals for alleviating problems, supportive counseling, problem solving, community referrals pre-bereavement and bereavement care.
Provides psychosocial assessments, crisis intervention, social work consultation, referrals,short term crisis counseling to facilitate discharge plans, and/or adjustment to illness, and complex discharge planning for patients and their families.
Provide psychosocial services to patients treated by the facility including in-center and home dialysis patients (if applicable) utilizing Social Work Theory of Human Behavior and accepted methods of social work practice.
Responsibilities will include completion of psychosocial assessments, involvement of patients in the development of individualized discharge plans, collaboration with the multidisciplinary team, and referrals to identified treatment and support services in the behavioral health system.