JOB SUMMARY: The Social Worker is responsible for assisting patients and their families with understanding and coping with the emotions and social effects brought on by changes in health status and care needs. Additionally, the Social Worker coordinates with Discharge Planning to assist patients and families to make appropriate post-hospital plans for continuing health care needs. The Social Worker is also the liaison to the community and government referral agencies. The Social Worker also provides social services to residents and families of Skilled Nursing Facility and Dialysis Unit.

PERFORMANCE DIMENSIONS AND TASKS

Essential Function

1. Identifies patients who require social service.a. Designs and implements protocol to identify patient/family needs.b. Coordinates screening protocols with other MMHS departments (i.e. Med-Surg/Swing, ER, Skilled Nursing, and Dialysis) so that patients are identified and referred.

2. Assesses each patient/family once it has been referred/identified.a. Assesses patient/family within hospital 24 hours post referral. Other outpatient referrals according to policy and procedure of unit.b. When Social Worker is absent, initial assessment is done by Social Service designee (Discharge Planning Nurse, Team Care Coordinator, Unit Coordinator) within 24 hours of identification.c. Implements system to ensure assessment is done and follow up on assessment done by Designee immediately upon return to MMHS.

3. Establishes and implements a plan that will ensure referral to appropriate resources in order to provide necessary continuity of care.a. Documents assessment and plan on appropriate forms.b. Communicates plan to other MMHS personnel needed to follow through with plan.c. Coordinates plan with all necessary outside agencies.d. Provides all necessary information to patient/family.

4. Maintains necessary MMHS committee and community memberships and professional affiliations.a. Is an active member of necessary MMHS multidisciplinary committees and care planning group.b. Attends pertinent community committee meetings as MMHS’s representative.c. Maintains appropriate professional affiliations.

5. Coordinates child abuse referrals. 6. Performance Improvement.a. Develops and implements an ongoing departmental performance improvement program.b. Program is congruent with the Hospital-wide program.c. Program meets regulatory requirements.d. Program is on going, pertinent and results in outcome analysis resulting in improved quality of care and services provided.

7. Additional responsibilities.a. Maintains effective interdepartmental communications.b. Provides at least yearly in-services to other MMHS personnel on identified areas of need.c. Participates in New Employee education/orientation as requested.d. Works to improve knowledge and expertise and to be current in areas of new ideas/changes.e. Assists with the development and monitoring of Social Services operational budget.8. SNF Responsibilities.1. Assist in meeting the psychosocial needs of each resident, their families and significant others as appropriate or necessary in coping with the effects of illness, disability, treatment or stay in the facility. The specific services include, but are not limited to, the following:a. Individual and family services designed to improve social functioning and reduce the psychosocial problems of residents.b. Advocacy, in cooperation with other facility personnel of residents’ rights. c. Assistance to residents, their families, and others as necessary or appropriate, in finding and utilizing financial, legal, mental health, and other community resources. d. Assistance in obtaining guardianship and conservatorship services for residents in need of such services. e. Enable residents to have access to available community programs and services as needed. 

2. Participation in resident care management to include the following:a. Assessment of residents’ psychosocial needs at admission and reviewed as needed and/or according to federal, State and Mee Memorial guidelines. b. Assisting in the development of a multi-disciplinary plan of care for residents. c. Participate as a member of the Interdisciplinary Care Plan Team. Assist with resident and family involvement in the Resident Care Plan Meetings. d. Documentation in the resident’s record in response to social service interventions. e. Review and revise the resident’s care plan at least quarterly.

3. Provide in-service education to the staff on the social and emotional needs of the residents and their families.

4. Utilizes the abilities of each resident to guide them to a self-determined style of life that provided a degree of satisfaction within the nursing and rehabilitation environment.a. Maintains and utilizes a comprehensive community resource file to meet specific resident needs.b. Support family members and significant others in their visitation of residents and comfort level with facility environment.c. Co-ordinates Advance Directive follow-up as needed.d. Coordinate with other members of the interdisciplinary team related to room changes.e. Monitors theft and loss and grievance procedures.f. Informs members of the Interdisciplinary Team when residents’ experience a psychosocial change of condition.g. Assist in discharge planning, transfers to alternate facilities if Mee Memorial unable to meet resident needs.h. Promote positive relationships with community organizations to develop and maintain good consumer relations.i. Assist with facilitating residents’ concrete needs of glasses, dentures, hearing aids, and clothing as needed.j. Participates as directed by the Case Management/Social Services Manager in the Mee Memorial Performance Program.

9. Dialysis Responsibilities1. Assists patients to understand their rights and responsibilities, and guide them in managing the physical, mental, emotional, and financial demands of End Stage Renal Disease:a. Manage Transplant Listb. Participates in Interdisciplinary Team meetingsc. Participates in Quality Assurance and Performance Improvement (QAPI) meetings.d. Ensures Care Plans are accurate and updated.e. Performs and documents depression screening.f. Assists in setting up transportation for patients.g. Sets up, leads, and documents patient/family care conferences as needed.h. Identifies resources for patients/families.

PERFORMANCE EXPECTATIONSAlthough each position has its own unique duties and responsibilities, the following expectations apply to all positions at MMHS..Essential FunctionPolicies and Procedures? Learns new procedures and accepts new assignments within reasonable timeframes, to be agreed upon by the employee and supervisor.? Maintains an awareness of changes in policies, procedures and protocol.? Arrives on time and prepared to start assignment.? Does not abuse paid time off.? Maintains universal precautions.? Attends department and other meetings as required.? Complies with MMHS’s confidentiality, safety, infection control, and exposure control policies.? Assists patients with courtesy regardless of age, gender, nationality and disability without prejudice or bias.? Complies with all policies and procedures as outlined in the adopted Policy and Procedures manual.? Wears I.D. badge.? Has completed mandatory safety and security education including annual fire/safety and hazardous materials review.? Demonstrates correct use of fire extinguisher.? Complies with annual physical examination as required.Customer Service? Complies with the MMHS’s twelve customer service standards.? Establishes and maintains a cooperative relationship with patients, staff and other individuals. Listens to and respects the ideas, feelings and opinions of others.? Demonstrates effective communication skills by conveying necessary information accurately, listening effectively and asking pertinent questions when clarification is needed.Teamwork? Demonstrates good judgment in handling situations not covered by written or verbal instructions.? Adapts to changes or unusual circumstances in a way that promotes cooperation and minimizes disruption in working environment.? Follows written and verbal instructions of supervisor.? Interacts with fellow employees in a way that promotes harmonious and cooperative working environment.? Recognizes and resolves problems; troubleshoots malfunctions in procedures and uses alternative methods if available.? Coordinates efforts of work effectively with others in a way that is productive.? Coordinates efforts of effective work activities that contribute to MMHS needs.