Summary:

This position is responsible for assisting in meeting the patient?s needs throughout the continuum of care. Guides patients, families, physicians, and to the appropriate community and adjunct resources that foster quality of life. Interviews patients and families/support systems to obtain an age-specific psychosocial assessment. Assists patients and families in adjustments to illness, disabilities, and resolving difficulties which interfere with the care management process. Provides psychosocial assessments and develops an interdisciplinary plan of care with the patient and stakeholders to best meet the needs of patients and families. Implements/assist with discharge planning services related to the complex patient.

Responsibilities:

• Develops plan of care in collaboration with the RN case manager, physician, and patient to secure the best discharge plan available to the patient.
• Assessment and planning for the social requirements of patient and family of patient in long term care planning.
• Maintains liaison with agency sources such as "Make A Wish"/"Ronald McDonald House".
• Discuss patient?s length of stay (LOS) of 4 days or greater, and outliers at weekly interdisciplinary/outlier meetings.
• Attends and actively participates in interdisciplinary patient care rounds on a weekly basis and works with the health care team to collaboratively formulate appropriate and realistic discharge plans.
• Assesses and continually reassesses the psychosocial/concrete needs of family members /support systems that may interfere with optimizing the patient?s care management (Medicaid, housing, food stamps, etc).
• Demonstrates awareness of the importance of addressing patient?s quality of life by maintaining current and up to date information of community resources and refers patients to those community resources which will enhance patient?s life to include initiating Medicaid transportation documents and meal ticket distribution when necessary. Initiates referrals to pharmaceutical companies to assist patient and families with high-cost medications.
• Provides resource/referral for counseling services and other recognized psychosocial therapies, child abuse referrals, adult protective service referrals, guardianship petitions and psychiatric petitions. Initiates referrals and appears in court as subpoenaed.
• Demonstrates competence to perform assigned patient care responsibilities in a manner that meets the age-specific and developmental needs of the patients served by the department.
• Provides referral to Spiritual Care and can assist in crisis intervention to patients and their family members involved in emergency trauma, deaths, loss of home, family violence, etc.
• Assess high-risk patients who exhibit behaviors that are maladaptive to the adjustment of the illness and /or disability.
• Change Management: Acts as a catalyst for change in the organization; responds to change with flexibility and adaptability to overcome organizational resistance and inertia; demonstrates the ability to focus and energize associates to work together for change; gains maximum support from others for new initiatives.
• Shaping the Organization: Devises systems and processes which improve the overall functioning of the organization; ensures that the organization?s systems, processes and people are integrated to achieve the mission in the most efficient and effective manner.
• Managing Process: Translates strategies into action steps; clearly assigns responsibility for decisions and tasks; sets clear objectives; monitors progress and achieves results. Conducts staff training/mentoring related to social work techniques.
• Achieving Results: Demonstrates the confidence, drive and ability to face and overcome challenges and obstacles to achieve organizational goals.
• Enhancing Clinical Outcomes: Works to improve the healthcare process in general and devises and implements strategies specifically directed at improving clinical outcomes.
• Utilizes evidence-based tools (Meditech, Midas, 3M) to analyze and identify trends/patterns of performance through variance reporting to improve quality, satisfaction, and decrease cost variation.
• Core Values: Demonstrates adherence to the CORE values of Santa Rosa Health Care.
• Performs other duties as directed.

Requirements:

Education

• Master of Social Work degree from an accredited college or university is required
• Ability to adapt quickly in an ever changing environment of care
• Excellent verbal and written communication skills
• Word processing/Excel skills
• Ability to prioritize work and manage multiple projects simultaneously
• Good attention to detail and accuracy
• Knowledgeable of social resources available to both inpatient and outpatient
• Analytical decision making and judgment Ability to maintain confidentiality in matters relating to patient/family

Experience

• Two (2) years acute patient care is preferred.
• Must have a good knowledge of the principles and practices of social work. Will be expected to utilize a variety of highly developed skills in individual and /or group methods
• Must have a good working knowledge of the impact of illness on the patient and family as well as an understanding of the age specific needs and cultural differences
• Must possess a high level of analytical abilities necessary to identify and plan for resolution of difficult psychosocial illness related problems Must possess and demonstrate higher level critical thinking skills, and have the ability to prioritize and achieve results in a fast-paced environment

Licenses, Registrations, or Certifications

• Must possess a valid LMSW to practice social work in the state of Texas CPR preferred

Work Type:

Full Time

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About CHRISTUS Health

CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.

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