The Social Worker in the Care Management Department reports directly to the Senior Director of Care Management and is an integral member of a hospital patient's care team, responsible for assessing and intervening to ensure the effective continuation of a patient's care after discharge from the hospital. This role will provide supervision of the ED Discharge Coordinator team. The social worker will be assigned to Emergency Department and Pediatric ED to assess and provide intervention for crisis and behavioral health patients. Will work closely with physicians, nurses, SBIRT Peer Recovery Coaches, Child Protection Program Coordinator, SAFE/DV, ED Discharge Coordinators, and other practitioners on the assigned units. In this role, coordination of services with patients, families, and community resources is an integral part of decreasing duration of extended stay patients in the Emergency Department. Social Worker is responsible for interviewing hospital patients and family members/caregivers; serves as a liaison between the hospital and community agencies. Facilitates family meetings to identify needs and develop continuing care plan; assessing psychosocial needs; counseling patients and family members to promote effective coping and treatment plan compliance. Other duties include assessing knowledge deficits; educating patients and family members about community resources, rights and responsibilities, advance directives, end-of-life care issues, health insurance, and navigating the health care system. Functions as part of a multidisciplinary team. As opportunities arise, the Social Worker will participate in department and hospital initiatives related to process improvement and patient care.
EducationMaster's in Social Work; equivalent experience or certification considered
Experience1-3 years prior social work experience in a hospital or other health care setting preferably doing discharge planning work, crisis and behavioral health experience, knowledge of local and state crisis and mental health systems
Skills- Cultural competency and willingness to work with patients of many different racial, national, ethnic, and religious backgrounds as well as different age groups and socioeconomic statuses.
- Basic computer skills (electronic medical record training is provided)
- Interview skills including active listening, open-ended questioning, and empathy
- Assessment skills to quickly develop thorough assessments and care plans
- Skill in, or willingness to learn, counseling and motivational interviewing techniques
- Willingness to engage with difficult or noncompliant patients or family members; willingness to discuss topics such as end of life care or substance abuse
- Ability to self-direct and negotiate competing priorities
- Ability to develop a wide-ranging working knowledge of services, referral processes and criteria, medical terms and needs, etc. (training is provided)
- Ability to work in a fast-paced environment; desire to engage with change processes and work closely with multi-disciplinary teams
- Ability to deescalate patients and families in crisis situations
- Experience in pediatric social work or related field and child abuse evaluation
Licensures, Certifications- Licensed in Maryland as a LMSW, LCSW or LCSW-C
Physical Requirements- Ability to move quickly about the Emergency Department as needed. Able to concentrate on details in a hectic environment.
Working Conditions- Work is performed inside the organization's offices, patient care units, or in-patient rooms. Job attendance is required during all types of weather conditions.
- Must carry on-call phone for evening and weekend call on a rotating basis with ability to come in to work if necessary during time off.
Conditions of Employment- Must speak, write, and understand English fluently both in person and on the phone.
Patient & Workplace Safety- Employee has knowledge and understanding of patient and workforce safety as it relates to job duties.
Patient Population- Demonstrates competency in the delivery of care and applies the knowledge to meet age-specific needs if applicable.
Principal Duties and Responsibilities- This position provides direct supervision to the ED Discharge Coordinator team and assists with collaboration between the Discharge Coordinator team, the ED Psychiatric providers, ED Physician/Providers, and ED Nursing department.
- This position will assist with daily guidance of the ED Discharge Coordinator team's caseload management, prioritization of tasks, and problem-solving with challenging cases with potential for extended stays.
- Serves as liaison between Care Management department and ED Nursing, ED Providers, and ED Psychiatry group regarding any issues related to behavioral health patients as well as the ED Discharge Coordinator team.
- Works daily with the Emergency Department multi-disciplinary team and others to establish the anticipated discharge date and needs for each assigned patient .
- Interviews patients, family members and significant others to obtain a relevant psychosocial assessment including a social determinants of care interview and using these findings to establish each patient care transition plan.
- Develops and implements a plan of care appropriate to identified problems. Shares resultant findings with the appropriate health care team members, physicians, and payer source.
- Arrange for the timely discharge of patients. Uses published guidelines and tools for monitoring length of ED stay and tools for the most effective use of post-acute services and community resources. Identifies, plans, modifies, and coordinates patient discharge needs, making appropriate referrals, and utilizing available community resources as needed for implementation. Formulates a plan that addresses the continuing needs of the patient following discharge from the ED setting.
- Works collaboratively with hospital based post-acute service liaisons to coordinate transition plans for patients. Adheres to the use of GBMC Health System preferred providers whenever possible. Makes suggestions for the addition of new services to this system-wide resource tool.
- Provides necessary services for effective post discharge placement in another facility, by obtaining necessary pre-authorization, transportation, and contacting (if necessary) the proposed facility regarding clinical information and services required.
- Collaborates with local and state agencies to ensure safe and effective discharges.
- May use individual, family and group counseling modalities and other recognized psychosocial therapies in assisting patients and family members. Offers suggestions for modifying behavior by recommending appropriate resources.
- Provides and facilitates completion of appropriate documentation for patient records in a timely manner.
- Attends educational in-services related to total cost of care, transition planning motivational interviewing and others as appropriate for continued licensure and for effective ongoing performance.
- Participates actively in problem solving to develop the most effective and efficient transition plan for each assigned patient.
- For all patients with a Primary Care Physician and Care Team in one of our PCMH's, communication about the proposed transition plan will be shared with the Ambulatory Care Management Team.
- Attends monthly staff meetings, weekly staff huddles and participates in committees as needed.
- Collaborates with outside agencies such as EMS, local police, and other state and governmental agencies to provide community intervention education.
- Documents all pertinent information gathered from assessments and interactions with patients, families and outside agencies.
Pay Range$61,955.01 - $105,323.51
Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs.
