Under the direction and supervision of the Director of Social Services and/or Social Services Specialist performs administrative support activities required for delivery of services from patient admission through discharge. The Social Services Assistant’s primary responsibility is to support social services staff with the goal to optimize professional care service provided to our patients.
POSITION RELATIONSHIP
Performs social service functions as a contract employee within the transitional/subacute units of contracted health facilities. Serves as member of interdisciplinary team, liaison to advocacy agencies, and support resource to residents, families and peers. Accountable to the Clinical Manager of the Unit (in DP of the Hospital)/ Administrator (FS SNF) for day to day operations and social services activities, to assure compliance with the regulatory agencies such as Department of Health Services, Title 22, and JCAHO. Collaborates with all levels of unit nursing personnel, including the Director of Nurses, physicians, consultants, and the IDT in assessing needs and providing education to the facility.
QUALIFICATIONS
1. PROFESSIONAL
a. Associate degree with a minimum of two (2) years’ experience in Long Term Care or human services. These guidelines may vary according to State regulations.
b. Any certification/licensure required by state regulations.
c. A working knowledge of basic services provided by various health and welfare organizations in the community.
d. Clinical experience working with individuals, families and groups.
e. Knowledge and skills necessary to provide services appropriate to the age of the patients served.
f. Knowledge and skills necessary to provide services appropriate to the age of the patients served.
g. Computer skills and knowledge of basic computer programs (must be able to prepare individual/departmental reports as position requires).
h. Current CPR certification.
2. PERSONAL
a. Must have strong communication skills, both oral and written
b. Demonstrated ability to be part of a team, ability to present precise and meaningful reports both verbally and in writing.
c. Ability to relate appropriately and effectively with others.
d. Possesses good judgment, organizational and time management skills.
e. Ability to work independently in the assessment and resolution of problems, as well as carry out the day to day function of the job without onsite daily social work supervision.
f. Maintains professional appearance.
g. Dependable, conscientious, honest, good attitude promotes safety.
h. Demonstrates understanding, discretion, patience, tact and diplomacy in dealing with residents, visitors, peers/staff, and administrative personnel.
i. Ability to prioritize multiple assignments.
j. Ability to cope with stressful situations
3. POSITION RESPONSIBILITIES
a. Educates patients/residents and families/significant others regarding their rights and responsibilities, health care decision making/advance directives, effective problem solving and the extent of community, health and social services that is available to them, including those necessary for effective discharge planning.
b. Support the identification of patient/resident discharge goals at admission and documents as warranted.
c. Participates in Utilization Management Process.
d. Responsible for communicating to center team members the estimated discharge date and updating electronic medical record.
e. Makes referrals as needed for post discharge care to appropriate agencies and suppliers.
f. Initiates and participates in completion of Discharge Transition Plan & Discharge Packet materials and orienting the patient/resident and family around the process.
g. May be involved in contacting patients/residents post discharge to ensure successful transition.
h. Assemble and prepare documents for discharge planning (hard copy or electronic process) per direction from Social Services staff.
i. Identifies medical-related social needs of patients/residents, provides appropriate services to meet the individual, as well as collective needs of patients/residents, and maintains records relating to the patients’/residents’ social work needs and care;
j. Apprises the Director of Social Services and/or Social Services Specialist and other staff regarding interdisciplinary issues, as well as maintenance of appropriate records;
k. Supports Social Services Department with departmental communication and record management.
l. Supports assessment process.
m. Participates in the development of a written, interdisciplinary plan of care for each patient/resident that identifies the psychosocial needs/issues of the patient/resident, the goals to be accomplished for those needs/issues, and the appropriate Social Services interventions.
n. Assists patients/residents in coping with their transition and adjustment to a long-term care facility including the social, emotional, and psychological needs.
o. Supports patient/resident and family members/significant others to assist in their
understanding of placement and facility issues in addition to referring them to the appropriate Social Service agencies when the facility does not provide the needed services.
p. Facilitates patient/resident transfer throughout the center to ensure a seamless transition and patient/resident adjustment.
q. Provides direct social services and counseling to residents, families and/or groups to enhance psychosocial functioning, spiritual, cultural, emotional, financial and physical well-being.
r. Initiates interview process with resident/family within 24 hours of admission to determine the social, psychological, financial, grief support, cultural, family, spiritual and health needs, in order to formulate a written assessment within 2 days of admission to the unit.
s. Develops a plan of intervention, based upon assessment, which addresses the resident’s physical and psychological problems, and in coordination with the recommendations of other health care disciplines involved in the resident’s plan of care.
t. Assists residents/families through individual or group education and conference to understand, accept and follow medical recommendations.
u. Performs interdisciplinary discharge planning and review for each resident within 48 hours of admission, with ongoing evaluation and documentation of plan involving resident/family and team member input.
v. Facilitates the admission agreement of residents to the facility through assisting with facility tours, assuring completion of the agreement and consent forms, and the provision of information covering rights and services.
w. Conducts regular room visits to residents and maintains regular contact with family either by phone or mail, whenever possible or reasonable.
x. Conducts monthly family groups on the unit to educate and assist families and significant others in coping with anxieties, grief, and the ongoing adjustment to the resident's illness and disability.
y. Conducts open, timely and professional communication and relationships with residents/family, team members, supervisors, and others in order to facilitate team work, to assure resident self-determination, and to update on any significant changes or concerns.
z. Participates and provides leadership in interdisciplinary team conferences on residents with other members of the staff, in order to develop, review and update individualized treatment goals and comprehensive plan of care.
aa. Provides consultation to members of facility staff, community agencies, and other persons or groups seeking guidance in efforts to solve the problems of residents.
bb. Communicates and interprets age specific data and responses to treatment; recognizes specific barriers to learning such as language, skill level, cultural issues, socialization factors, e.g. separation, anxiety, loss of independence, loss of livelihood, etc.
cc. Assists in coordinating two major family functions per year, such as Holiday Parties, Easter Hunts, etc., which can be held in lieu of regular family groups and planned in conjunction with Activity Director.
dd. Maintains resident dignity, quality of life, confidentiality of information and serves as advocate for the resident at all times (i.e. Liaison with advocacy agencies, assuring voting privileges, monitoring and reporting of elder/dependent and child abuse, resolution of grievance/complaints, monitoring of theft and loss; etc.).
ee. Works cooperatively with resident/family, administration, and facility staff to assure that the physiological and concrete needs are maintained for the well-being of the resident (i.e. optical, dental, audiological, clothing, etc.).
ff. Performs such other functions as are identified and requested by supervisor.