The Medical Social Worker provides professional clinical social work, and discharge planning services as appropriate to individuals, families, and groups in the assigned social work area. Works with the social, emotional, and related financial problems precipitated by or resulting from illness, medical treatment and/or hospitalization. Provides services for Long Term Care, Respite Care, Ventilator Care, and Rehabilitation.

Identifies, screens and assesses in a timely manner, those residents families and significant others who require social work services.

Provides ongoing social work treatment to residents, families and significant others for health-related psychosocial problems, based on goals agreed to by resident, family and significant others. Utilizes individual, family, group work and crisis intervention methods to provide high quality care and services.

Provides psychosocial assessment, including the resident’s previous experience to receiving care and treatment, any recent changes in the resident's activities of daily living, mental or physical status or family support. Information is documented and shared with the treatment team from day of admission.

Assists residents and family members in reviewing personal health care and end-of-life decisions as they relate to formulating an Advance Directive, do not resuscitate or do not hospitalize on a plan to go into Hospice Care.

Leads support groups for residents, families and/or significant others.

Provides educational programs for residents, families and staff through In-Services: Resident’s Rights, Family Council meetings, and Unit Programs to assist in the sensitivity to issues around aging, nursing facility care and illness.

Assists residents in gaining access to community services/programs; i.e., M.S. Friends Group, Post Stroke Group, Overcomers Camp and trips to the mall, etc.

Integrates social work services into the total care of the resident within Long Term Care and community by participating in such meetings as weekly Inter-disciplinary Care Planning meetings on assigned units/areas. Coordinates the discharge planning, in order to ensure the continuity of care, and acts as resident advocate, as needed.

Documents promptly on the social work forms/or other approved area of the resident’s medical record, and care plan as per departmental policy, the social work screening, assessment, treatment, progress and outcomes, evaluation and recommendations, in order to provide timely, integrated, continuous care of high quality. Completes required departmental forms to document services provided, including departmental statistics.

Evaluates assigned delivery of social work services to uncover unmet needs, resident/family special needs and further areas of social work development including services to non-English speaking residents.

Develops knowledge of hospital and community resources and refers residents, families and hospital staff to the appropriate service in the hospital and/or in the community, in order to insure continuity and quality of care.

 RESPITE CARE

 Initiates discharge planning prior to or upon admission to the short-term program: up to 30 days annually.

Assesses resident’s need for an alternative care level; i.e., Long Term Care, Rehabilitation, Assisted Living, Group Care Home, JAC, Statewide Respite Care Program etc., and initiates applications and preadmission screenings necessary for entrance to care facilities. Coordinates discharge planning including community home care and support services.

Monitors outcome of after care and health services.

 REHABILITATION CARE

Completes initial assessment for skilled nursing facility care and treatment, including assistance to residents and families in their understanding of changed physical functioning and related emotional and social aspects and discharge plans.

Provides in-patient and out-patient treatment resources to help residents and family members in determining a plan of treatment and need for after care services.

Plans with the resident, family and inter-disciplinary team for the plan of care and for the plan of a timely and appropriate discharge, including resourcing benefits through insurance and community services entitlements.

Attends various related committee meetings (i.e., I.D.C. Team, Utilization Review, Accounts Receivable Bioethics, Family Council Meeting, Resident Council, HIPAA, Quality Assurance).

Participates in the Quality Assessment/Quality Improvement Program of the Department, in order to further improve the quality of social work services in the medical center. Participates in departmental staff meetings, surveys (i.e. NJ DOHSS, US DOJ etc.) and committees as appropriate, making recommendations and assisting in completing assigned work.

Responsible for teaching/training professionals or non-professionals inside or outside the hospital, when assigned, in order to improve the quality of knowledge of practice and improve upon health care services.

Represents the Department and the facility at meetings and conferences, as needed.

Participates in studies, surveys or research, initiated or approved by the Long Term Care of Medical Social Services Department, in order to develop knowledge about effective treatment, or improve quality of delivery of service.

Continues professional development through formal and informal education and training with specific age related populations. Attends scheduled inservice programs in order to enhance assessment and treatment skills with residents, families and significant others. Participates in professional organizations.

Performs all other duties as required including rotation to other areas than the one assigned within Long Term Care.