The Licensed Clinical Social Worker uses advanced clinical practice skills to manage patients with complex psychosocial co-morbidities. The Licensed Social Worker is expected to demonstrate the knowledge and skills necessary to provide care based on the physical ability, intellectual development, psychosocial, education, and safety needs of the geriatric patient. Therapeutic clinical interventions are an important part of the role of the clinician, however, this is not a psychotherapy position.
Patient Population Served:
The Licensed Clinical Social Worker on the Geropsychiatry unit performs biopsychosocial assessments of patients in a secure, inpatient setting, leading to the selection and coordination of continuing treatment services which permit the individuals to maximize qualities of life consistent with their diagnoses and prognoses.
Essential Position Functions:
Facilitation and coordination of care and services
Considers patient needs to include medical, physical, psycho social, spiritual, financial, and emotional aspects of care.
Communicates and collaborates with all members of the health care team, including the patients, management, physicians, payors, interdisciplinary team members, and community agencies regarding patient's needs, goals, treatment plan, and response to treatment, as appropriate.
Actively participates in inter-disciplinary rounds, providing relevant clinical information, psychosocial findings, status of care coordination and ongoing discharge planning efforts.
Facilitates or participates in patient/family conferences with or without interdisciplinary team members designed for gathering information, problem identification, and/or to resolve issues around in-hospital and post-hospital care.
Actively participates in the admissions team process to review incoming referral documents and assess for clinical and appropriateness. Collaborates with agencies, physician practices and families to obtain information needed to make admission decisions.
Assists with explanation and obtaining of advanced directive documentation.
Collects, analyzes, enters and reports social services data related to patient care and actively participates in ongoing quality improvement initiatives.
Completes referrals and paperwork necessary to facilitate patients' efficient movement through levels of care.
Maintains appropriate documentation.
Performs all functions according to hospital/office policy and applicable regulatory and professional entities/guidelines, standards, protocols and procedures within the scope of their practice and dictated by the department in which they work.
Discharge Planning: Facilitate efficient access to high quality care
Identifies discharge planning needs of patients through chart review, patient interview, and discussion with other caregivers and/or via information exchange at multidisciplinary rounds.
Develops and communicates discharge plan to patients and other caregivers as appropriate.
Maintains detailed notes regarding all aspects of discharge planning process.
Manages each patient's transition through the continuum of care until discharge.
Coordinates home health and other in-home referrals as needed.
Initiates MEA paperwork process and guides family through the process of applying for community based residential care as appropriate.
Collaborates with the community at large to develop plan for complicated clinical care which requires multi-agency involvement.
Implements conflict resolution strategies in order to present a united message to patients and families and to reduce the impact of psychosocial barriers on discharge planning.
Non-Essential Position Functions:
Participate in hospital/unit committees as appropriate.
Participates in all hospital and community education
Perform other duties as assigned or as judgment or necessity dictates.
MSW from an accredited graduate school. Licensure, or license eligible, in the State of NH.
Three to five years experience in hospital and ambulatory setting. Geropsychiatric experience preferred.