Under the direction of department leadership, Social Work staff provides social work services consisting of comprehensive care management, discharge planning, continuing care services, and social work services including crisis intervention. In addition, the Social Worker is responsible for the education addressing physical, psychosocial, financial, environmental, and other needs of patients and families and/or significant others. Care management is not a profession in itself but an area of practice within the social work profession.

Essential Job Functions

• Supports and models behaviors consistent with the mission and philosophy of Billings Clinic and department/service.
• Assesses patient medical records for treatment plan, identifies actual and potential discharge needs at the time of admission for assigned patients.
• Identifies, screens and assess patients who require social work services in a timely manner.
• Integrates social work plan into overall patient care plan through participation in interdisciplinary team. Collaboration may include RN care management, physicians, nurses and other members of the health care team as service area dictates. Promotes collaboration and communication among team members.
• Provides patient, family, significant other education and emotional support utilizing individual, family and group modalities (care conferences). Meets with patient, family, significant other as appropriate to develop plan of care taking into consideration choice, support network(s), resource needs (financial, housing, transportation, etc.), and appropriate level of care. Provides crisis intervention and support on adjustment to illness/disability and coping skills.
• Identifies physical, psychosocial, and spiritual needs and incorporates them into the plan of care. Demonstrates sensitivity and awareness about population specific needs or special issues related to culture, race, gender, age religion, sexual orientation, etc.
• Demonstrates the ability to identify symptoms/indicators of abuse, neglect, and exploitation in specific patient populations and provide appropriate interventions, including mandated reporting.
• Assess and respond to legal issues such as Living Wills, Durable Power of Attorney, guardianship, etc.
• Understands and utilizes hospital and community based financial resources and entitlements such as SSD, SSI, Medicaid, charity care, mental health, HCFS, Patient Financial Representatives, Public Health and other outside resources as needed.
• Coordinates and implements discharge/transitional planning activities within expected length of stay in collaboration with the multidisciplinary team. Accountable for appropriate and patient focused discharge planning; including placement in alternative living environments. Advocates on behalf of patients and takes a lead role assisting patients with complex psychosocial needs.
• Keeps supervisor informed of barriers to discharge, patient/family dissatisfaction, and/or agency conflicts.
• Coordinates with referral agencies as indicated to ensure services are in place before discharge. This includes providing necessary paperwork in a timely manner in order to process the referral and enhancing positive working relationships with community agencies.
• Demonstrates and utilizes knowledge of internal and external agency services/resources related to the needs of specific patient populations and the ability to be creative in coordinating services.
• Refers patients, families and significant others to appropriate services to ensure continuity and quality of care (information and referral).
• Monitors the need for revisions in the care plan and makes recommendations to physician(s) and interdisciplinary team when indicated.
• Demonstrates the ability to evaluate compliance with medical/psychiatric treatment protocols and intervene to address barriers.
• Serves as a resource to staff on psychosocial needs of patients and families, resources and discharge/transitional planning.
• Documents care management interventions in medical record including patient, family and/or significant other communication, discharge/transition plan, and disposition status.
• Documentation is timely and reflects professional practice.
• Maintains data and reporting information as required by department and other programs.
• Provides utilization review functions as required by the department.
• Identifies service gaps and participates in hospital and departmental programs to address and improve quality of care.
• Maintains competency in all organizational, departmental and outside agency environmental, employee or patient safety standards relevant to job performance.
• Adheres to regulatory, legal, compliance, and professional licensure/certification requirements in day to day practice.
• Participates in continuing education, department planning, work teams, and process improvement activities.
• Adheres to departmental and organizational policies addressing confidentiality, infection control, patient rights, medical ethics, advance directives, disaster protocols, and safety.
• Performs other duties as assigned or needed to meet the needs of the department/organization.