Conduct, by phone, comprehensive bio - psychosocial assessment and reassessments of identified high risk Members. Assess social service referrals for appropriateness and make the necessary recommendation for care plan.
Assesses patient awareness of advance directives; assists with accessing advance directive forms/information and facilitates discussion of advance directive wishes, if necessary, with the healthcare team and the patient's family/support persons.
As a member of the interdisciplinary team, assesses patients' psychosocial status, strengths and areas of need that may affect rehabilitation and optimal treatment outcomes as part of the comprehensive patient assessment.
The Social Worker is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patients resources and right to self-determination.
The Social Worker position provides group, individual and family therapy as well as organizing and directing treatment resources, discharge planning, patient progress, compliance with regulatory and accreditation standards and assuring that related issues are effectively addressed and communicated to the patient, family and others involved in the treatment process.