Home Health Social Worker - Memorial Health

Performs duties relevant to addressing the psychosocial concerns of Memorial Health System patients and families. Mobilize health, psychosocial, and economic resources in order to promote optimal outcomes for the patient and family.  Collaborates and partners with patients and providers as an integral member of the care team and act as a liaison by advocating between the patient, family, healthcare providers, services, and community agencies in order to expedite use of healthcare services in the community and across the continuum of care. 

Education:

• Master’s degree of Social Work from a School of Social Work accredited by the Council on Social Work Education. 

Licensure/Certification/Registry:

• Illinois Licensed Social Worker required within six months of hire date.
• Must possess a valid IL driver license and must be deemed as an acceptable driver in accordance with the MHS Fleet Safety Policy (five year MVR will be required).

Experience:

• Experience working with adults across the life span presenting with chronic or serious illness
• Experience identifying and coordinating the needs of chronically ill patients and families as well as supporting the care team
• Understanding of psychosocial implications of illness, hospice and/or home care death and dying issues.
• Knowledge of local community resources.
• Knowledge and understanding of individual development and human behavior as it relates to the effects of illness and of the influence of culture on healthcare

Other Knowledge/Skills/Abilities: (Skills may be combined as needed; choose 5-8)

• Analytical Thinking: Developing a deeper understanding of a situation, issue or problem by breaking it down or tracing its implications step-by-step. It includes organizing the parts of a situation, issue or problem systematically; making systematic comparisons of different feature or aspects; setting priorities on a rational basis; and identifying time sequences, casual relationships, or if-then relationships.
• Change Leadership: Ability to energize stakeholders and sustain their commitment to changes in approaches, processes, and strategies.
• Collaboration: Ability to work cooperatively and inclusively with other individuals and/or teams not formally lead; working together as opposed to working separately or competitively.
• Communication: Ability to use written and spoken communication in formal and informal situations to convey meaning, build shared understanding, and productively move agendas forward.
• Community Collaboration: Ability to align one’s own and the organization’s priorities with the needs and values of the community, including its cultural and ethnocentric values, and to move health forward in line with population-based wellness needs and national health agenda.
• Intellectual Curiosity: Underlying curiosity and desire to know more about things, people, and issues, including the desire for knowledge and staying current with health, organizational, industry, and professional trends and developments. It includes pressing for more precise information; resolving discrepancies by asking a series of questions; and scanning for potential opportunities or information that may be of future use, as well as staying current and seeking best practices for adoption.
• Innovation: Ability to approach one’s work and the organization in new and breakthrough ways, including applying complex concepts, developing creative new solutions, or adapting previous solutions in promising ways.
• Interpersonal Understanding: Ability to accurately hear and understand the unspoken or partly expressed thoughts, feeling, and concerns of others, especially those who may represent diverse background and very different worldviews.
• Professional and Social Responsibility: Demonstration of ethics, sound professional practices, social accountability, and community stewardship. Acting in ways that are consistent with one’s values and what one says is important.
• Self-Confidence: Possesses a belief in one’s own capability to accomplish their work. This includes confidence in one’s ability as expressed in increasingly challenging circumstances, and confidence in one’s decisions or opinions.
• Strategic Orientation: Ability to consider the business, demographic, ethno-cultural, and regulatory implications of decisions and develop strategies that continually improve the long-term success and viability of the organization.
• Current driver’s license, vehicle insurance, and transportation
• Excellent PC skills, including the use of Microsoft Office products. Familiarity with EMR clinical products preferred.

1. Biopsychosocial Assessment
   1. Utilizing specialized knowledge and experience, make assessment of patients’ psychosocial needs, home situation and economic constraints
      1. Psychiatry assessments must be completed within 3 working days of patient’s admission and include regulatory mandated information.

1. Community Resources
   1. Serve as liaison between patients/ families and community agencies
   2. Coordinate information and referrals for financial and community resources to link patients/families to the appropriate resources.
   3. Serve as resource to clinical team, patients and families regarding entitlement to programs and support services
   4. Develop strong working relationships with internal and external healthcare organizations and community resources.
   5. Work with patients to formulate an individualized plan to obtain medication, particularly, in light of Medicare coverage limitations including the facilitation of enrollment in various drug companies’ patient assistance programs when warranted

1. Care Delivery
   1. Work closely and collaboratively with the clinical care team across sites of care
   2. Assist the team with care delivery by scheduling appointments, arranging interpreters, assisting with the completion of forms, ensuring that patients can access services, and arranging transportation to and from medical appointments as needed
   3. Participate in clinic office visits, team rounds, or family conferences with when needed based on site of care

1. Care Transitions
   1. Coordinate patient care with other disciplines involved in the plan of care and maintain appropriate documentation
   2. Confer with the patient, family, and clinical team to obtain information to coordinate efficient and quality patient care.
   3. Build relationships with primary care providers, skilled nursing facilities, and the community to promote continuity of care

1. Embody the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values:

• SAFETY: Prevent Harm - I put safety first in everything I do.  I take action to ensure the safety of others.
• COURTESY: Serve Others - I treat others with dignity and respect.  I project a professional image and positive attitude.
• QUALITY: Improve Outcomes - I continually advance my knowledge, skills and performance.  I work with others to achieve superior results.
• EFFICIENCY: Reduce Waste - I use time and resources wisely.  I prevent defects and delays.

1. Support
   1. Provide crisis intervention and supportive counseling for patients and their families as needed
   2. Serve as patient advocate, assisting with navigation of patient eligible resources and programs
   3. Provide patients and families with support and information to overcome personal and environmental difficulties which pre-dispose toward illness or interfere with obtaining maximum benefits from medical care
   4. Assist patients to effectively utilize available resources to meet their personal health needs and help them develop their own capabilities
   5. Evaluate patients’ ability to independently manage self and locate alternative resources when limitations are identified

1. Advance Care Planning
   1. Maintains a working knowledge of relevant medical/legal issues that impact patient care, e.g., advance directives, power of attorney, and guardianships.

1. Counseling
   1. When requested, provide group, individual, and family counseling to patients and their families as requested

1. Discharge Planning
   1. Initiate discharge planning when patient is admitted.
   2. Assure that discharge plans are secured when patient is medically ready for discharge
   3. Assure that all necessary information has been transmitted to next provider of care.

1. Record documentation for all social work activities in the electronic medical record in a timely and thorough manner.
   1. Psychiatry colleagues must document in record after each session and supports information needed for Utilization Review criteria and the patient treatment plan.

1. Adhere to department productivity standards.

1. Participate in the monitoring of quality and utilization metrics and participates in improvement efforts to refine the delivery of care to maximize clinical, quality, and fiscal outcomes.

1. Assists, as needed, in the staff training, new employee orientation, student education, community education, in-house activities, and general public relations activities.

1. Refer to ancillary teams when warranted.

1. Aware of and comply with department and hospital policy and procedures.

1. Demonstrates knowledge of care for older adults through accurate assessments, treatment and effective implementation of interventions.

1. Adhere to the NASW Code of Ethics.

1. Comply with the Illinois Mental Health Code and Confidentiality Act.

1. Participate in continuing education and in-service training to support professional growth and expertise.

1. Perform other related duties as assigned.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.