Provides therapeutic intervention and social work services to patients and their families to enhance comprehensive, integrated, and uninterrupted care in the hospital and to have continuity of care in the community.
Principal Accountabilities:
Include, but are not limited to:

Assesses the patient’s psychosocial situation in relation to the medical and needs and plans appropriate interventions and treatment goals to improve patient/family functioning.

Interviews patients, family members, and/or significant others identified through case finding or referrals to assess needs for social work and/or interventions related to social determinants of health. Participate and Provide input in Multidisciplinary Rounds: Psycho/Social Context Function as resource and advocate on behalf of the patient and family for discussions involving Advanced Care Planning Other duties as assigned.

Provides psychosocial support to patients and families during adjustment to illness and life changes. 

A. Provides preventive, protective, or supportive services to patients who are in or threatened by situations detrimental to their well-being.

B. Collaborates with the health care team regarding in-hospital needs and post-hospital care.

C. Maintains current with available psycho-social services programs/services and provides relevant information to patients, families, staff, and community organizations.

D. Develops and maintains collegial relationship with community organizations.

Coordinates and maintains a viable psychosocial discharge planning program for the assigned service area to identify patient needs and plan for appropriate after-care services.

Ensures continuity of care through comprehensive and appropriate discharge planning with patient, family, and/or significant others.

Long Term /Custodial Care  Acute rehab, Sub-acute rehab/Skilled Nursing Facility (SNF) LTAC, Dialysis, Hospice  Homelessness solutions and resources

Documents appropriate data from psycho-social assessments, individual contacts, family interventions and discharge planning according to department policy and procedures and State, Federal, and Joint Commission stipulated requirements.

Develops a social service network with city, state or other governmental services that serve the needs of the assigned patient population, to assist patients in obtaining such services as, food stamps and other financial supports and assistance in obtaining transitional housing.

Evaluates psycho-social services program objectives and results and participates in program planning and improvement in accordance with the mission of the hospital and department.

Maintains confidentiality in accordance with hospital and departmental policy and professional standards. May accompany patients to obtain benefits, entitlement, or other services.