Medical Social Consultant - Continuum of Care

Position Summary:

Report to the Director of Ambulatory & Community Social Work with dotted line reporting to the Sr. Director Service Line Management for programmatic guidance specific to the care of the Orthopedic and Spine patient population. The Social Worker provides counseling, comprehensive psychosocial assessment and related functions for patients identified as needing Social Work support or intervention. Serves as collaborative partner with the members of the multidisciplinary healthcare team to facilitate an appropriate transitional care plan. A progression of responsibility is evident in this series and ranges from simple, routine, and repetitive duties performed to duties that are complex and highly diversified requiring the exercise of discretion and independent judgment performed under administrative direction.

Duties & Responsibilities:

• Meets directly with patient/family to perform a comprehensive psychosocial assessment including social, emotional, cultural, mental status, environmental and financial circumstances in conjunction with an interdisciplinary assessment of the patient. Recommends a plan of intervention based on mutually established goals.
• Conducts and documents initial psychosocial assessment, health related social needs, appropriate interventions, and expected transition in a comprehensive, clear, timely and legible manner, addressing:
  
  • Reactions to illness and different abilities, especially the chronically and terminally ill.
  • Adjustment to the medical setting and compliance with the treatment plan
  • Adjustment/coping with post-hospital/clinic care needs and linkage to community resources
  • Facilitates health care surrogacy and/or guardianship process, for patients deemed non-decisional by medical team, in accordance with Illinois Health Care Surrogate Act and hierarchy. Leads efforts to find family and/or surrogate decision maker for patients. Collaborates with complex service line and the legal department to file for Illinois state guardian when necessary
  • Coordinates groups for supportive interventions or educational opportunities
  • Addresses financial issues related to insurance coverage and payment, refers to Financial Case Management Unit
  • Conflict resolution, management of complex family dynamics impacting plan of care and discharge planning, coordination of complex clinical case conferences
  • Investigation, management and reporting of suspected abuse or neglect of minor children and vulnerable adults. Facilitates involvement of Illinois Department of Children and Family Services (IDCFS). Facilitates involvement of Illinois Department on Aging. Identifies, reports, provides intervention, offers safety planning, and documents cases of suspected Intimate Partner Violence/Domestic Violence of adults. Facilitates involvement of Chicago Police Department when deemed necessary
  • Assesses for depression and suicidal ideation using validated tools. Addresses psychiatric symptoms and substance use disorders
  • Provides supportive care for patients considered for hospice/palliative care and participates in family meetings to discuss goals of care and end of life planning
  • Address needs for patients who are unhoused
  • Performs assessments of the physical environment and adequacy of support systems to prevent a crisis and/or hospitalization
  • Member of Behavioral Response Team
• Conducts post discharge follow up phone calls to address any post discharge social needs.
• Projects include but not limited to Social Work-related tasks:
  
  • Quality Improvement committees and other committees where Social Work involvement is warranted
• Coverage/Training/Clinical Performance Activities may include:
  
  • Provides cross coverage to other clinics as assigned
  • Assist with training new staff and student interns
  • Assists in data collection regarding interventions and financial impact
  • Uses data to drive decisions and plan/implement performance improvement strategies related to social work for assigned patients/units, including financial, clinical, quality, and patient satisfaction data
  • Collects data for discharge delays, over-utilization of resources, avoidable days, and other data for specific performance and/or outcome indicators
  • Participates in the development, implementation, evaluation, and revision of tools in collaboration with healthcare team
  • Assumes responsibility for professional development and social work clinical education requirements by participating in workshops, conferences and/or in-services
• Based on Program needs, develop and lead Groups or education sessions
• Provide any functions that may be considered appropriate to the role or services as a Social Worker
• Maintains competency for Licensed Social Worker (LSW), Clinical Licensure (LCSW) and credentialing of program to allow for the ability to generate revenue under billing of services.
• Other Duties as assigned
• Ambulatory Medical Social Work
• Manages outpatient social work needs through placement coordination and resource utilization
  
  • Attends Unit/Clinic based rounds/huddles
  • Utilize appropriate software to cultivate resources mapped directly from the Patient’s medical, social, and cultural needs, insurance coverage, financial status, geographical preference, and physician recommendations
  • Coordinates action plans when barriers are present to facilitate resolution
  • Escalates to supervisor/director when barriers are present to facilitate resolution. Proactively identifies and resolves delays and obstacles to discharge. Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues and system problems
  • Coordinates discharge planning to ensure a timely discharge (placement or return to the community) through early identification, assessment, and intervention for post-medical center care needs, to ensure that the patient is discharged, when medically ready, to: Other Hospitals, Rehabilitative facilities, Extended care facilities, Sub-Acute Care or Group Homes, Psychiatric and Chemical Dependency Care, and Return to home or other living arrangement.
• Demonstrates knowledge of community resources and an ability to connect patients and families with these resources. Acts as an advocate on behalf of the patient who requires assistance to gain access to needed information, resources, or services
• Engages Clinic Providers and Staff through regular contact/updates and attendance at clinic/provider meetings
• Facilitates appropriate transitions of care by engaging the clinical team and referring the patient to care coordination, and other internal resources as appropriate
• On- Call responsibilities:
  
  • On call duties when necessary to provide social work support after normal business hours and follow up with documenting on call activities.
  • Disaster intervention and support when activated
  • Other duties as assigned