Clinical Social Worker 2

%

of time

Essential Function (Yes/No)

Key Responsibilities

(To be completed by Supervisor)

40%

• Provide psychosocial assessment and interventions on the basis of preliminary risk screening, assesses patient's and family's psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope for transplant patients on both an in-patient and out-patient basis.

• Intervene with patient and families regarding emotional, social and financial consequences of illness and/or disability; illicit support of CSW III, as appropriate to deal with families exhibiting complex family dynamics that impact directly on patient care and discharge.

• For patients with significant or intensive psychosocial needs, serve as primary care manager, working in close collaboration with case manager to manage the clinical resources and transition planning for patient within assigned caseload from admission through discharge, actively working to identify/eliminate barriers to delivery of clinical services required to advance care and promote timely discharge once medically ready. As primary care manager:

1. Meet with provider, care team and patient to identify goals for medical readiness and formulates primary/back-up discharge plan

2. Coordinate and lead multi-disciplinary rounds and monitor discharge milestones, assign accountability for tasks, and proactively identify and address/escalate barriers to timely discharge

3. Reassess patient, as needed, to make real-time adjustments to discharge plan

4. Complete all required documentation in APeX screens and patient records

10%

• Active member of the interdisciplinary team, specifically on complex psychosocial cases, contributing to team goal setting and plan of care through attendance, participation in, and facilitation of multi-disciplinary rounds (MDRs).
• Participate in discharge planning activities for complex patients, to drive timely discharge when patient medically ready and to provide appropriate linkage with post-discharge care providers
• Work in a collaborative practice model, facilitating care coordination with the multidisciplinary treatment team for care progression to optimize patient outcomes and timely discharge when patient is deemed medically ready.
• Intervene with patient and families regarding emotional, social and financial consequences of illness and/or disability; deals with families exhibiting complex family dynamics that impact directly on patient care and discharge.
• Educate patient/family and physician regarding post-acute options and addresses issues of choice.
• Assess, intervene with and report domestic violence, child/elder abuse and other reportable situations in accordance with legal mandates and UCSF policy and procedure. Collaborate with Psychiatry and other appropriate teams on cases with psychiatric holds or primary mental health/substance abuse problems and/or patients expressing suicidal or homicidal ideation.
• Knowledge and skill with substance use and dependence assessment and intervention strategies, mental illness, end of life/bereavement, benefits and entitlements, and adjustment to illness.
• Serve as a resource person and provide counseling and intervention related to treatment decisions and end-of-life issues; identify surrogate decision maker, facilitate completion of Advance Health Care Directive and the POLST; when appropriate, coordinate application for probate conservatorship.
• Comply with Department standards for timely submission, accuracy and completeness of documentation in the Medical Record and collects all required statistical data.
• Attend department, hospital and community in-services related to field of practice.
• Participate in quality improvement activities and program planning for the Department, Hospital and Service Lines.
• Provide oversight and direction for activities delegated and performed by the Resource Coordinator and/or Patient Care Navigator.
• As available and under the direction of the Social Work Supervisor, provide clinical supervision to CSW II staff for the purpose of LCSW licensure in compliance with the California Board of Behavioral Sciences (BBS).
• Participate in coverage as needed and assigned.
• Compliant with all UCSF policies relevant to scope of work.
• Comply with Department standards for timely submission, accuracy and completeness of documentation in the Medical Record and collects all required statistical data.
• Advanced written and verbal communication skills required.
• Comply with documentation standards in timely fashion. Basic computer skills required.
• Collaborate and communicate with the multi-disciplinary transplant team on evaluation, listing, and management of pre and post-transplant patients.
• Develop materials and provide transplant education to patients, families, community and staff.
• Facilitate transplant support group and transplant education seminars as appropriate.

10%

5%

10%

5%

5%

10%

5%

100%

(To update total %, enter the amount of time in whole numbers (without the % symbol - e.g., 15, 20) then highlight the total sum (e.g., 1%) at the bottom of the column and press F9. The total sum should add up to 100%.)