Headquartered in Wilmington, Delaware, ChristianaCare is one of the country's most dynamic health care organizations, centered on improving health outcomes, making high-quality care more accessible and lowering health care costs. ChristianaCare includes an extensive network of outpatient services, home health care, urgent care centers, three hospitals (1,299 beds), a free-standing emergency department, a Level I trauma center and a Level III neonatal intensive care unit, a comprehensive stroke center and regional centers of excellence in heart and vascular care, cancer care and women's health.

ChristianaCare Offers

• Full Medical, Dental, Vision, Life Insurance, etc.
• Two retirement planning offerings, including 403(b) with company contributions
• Generous paid time off with annual roll-over and opportunities to cash out
• 12 week paid parental leave
• Tuition assistance
• Incredible Work/Life benefits including annual membership to care.com, access to backup care services for dependents through Care@Work, retirement planning services, financial coaching, fitness and wellness reimbursement, and great discounts through several vendors for hotels, rental cars, theme parks, shows, sporting events, movie tickets and much more!

PRIMARY FUNCTION:

To assist patients and families to identify social, emotional, and environmental needs and to connect them with available resources/ services through the provision of a full spectrum of discharge planning and social work services.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

Works with the patient, family, and other members of the health care team to formulate a discharge plan that provides the patient services in the appropriate post-acute care setting. Gathers and assesses information regarding the patient's physical needs, mental status, family support system, financial resources, and available community and governmental resources. Employs assessment to develop a comprehensive case management plan that will address the patient's goals of care and identified needs for discharge planning. As part of the discharge plan development process, collaborates with other healthcare professionals in multi-disciplinary meetings and patient rounds. Receives updates and guidance regarding Utilization Management from appropriate UM staff to assist with length of stay coordination.

Determines specific objectives, goals, and measures that are designed to meet the patients' needs that have been identified through assessment. The plan will be action-oriented and time-specific including collaboration with utilization management to manage length of stay. Maintains contact with the patient's third-party payors to ensure the most cost-effective plan of care is being carried out and appropriate in network providers are being utilized.

Provides information about resources and options available in the community and coordinates service delivery. Interprets patient/family needs and provides information concerning the availability and limitations of resources. Educates and addresses concerns with service delivery including service gaps and access issues. Implements discharge plan through service referral and coordination activities. The Social Worker always assures that the patient is given the choice regarding post-acute agencies and services.

Screens high-risk patients and consults attending physicians regarding potential discharge planning problems identified because of this process. Interviews and assesses referred and high-risk patients to determine the need and desire for social work services.

Provides factual information based on current knowledge, to provide psychosocial support and assist the patient/family in coping with their disease to improve their overall health care management. Educates the patients and families regarding various symptoms and consequences related to specific diseases, conditions and hospitalization. This information will also include specifics regarding methods of professional intervention and description of the process of social work intervention in a medical setting.

In accordance with established clinical guidelines, standards, and pathways, establishes a comprehensive discharge plan for those patients with post-acute care needs. The Social Worker will organize, secure, integrate and modify the resource necessary to meet the goals stated in the discharge plan. The Sr Social Worker will monitor patient care across the continuum through follow-up with patients, families, and community services.

Represents patient/family by intervening, negotiating, and promoting their concerns. Problems requiring advocacy may include individual and class inequities or inadequate and non-existent hospital and/or community resources, i.e., insurance benefits, housing, etc.

Maintains pertinent and timely documentation in patient's medical charts and

departmental records. Accurately maintains required departmental statistical data.

Collects and maintains specific information required for performance improvement indicators and research projects. Utilizes the department Quality Service Plan to address service issues as needed.

Performs patient/family evaluations and histories. Provides psychosocial support through individual, group, or family counseling, as needs dictate. Continuously reviews service area for group support needs and opportunities.

Represents ChristianaCare, when requested, through participation on community/state boards, committees, panels, court hearings, etc.

Attends regularly scheduled staff meetings, i.e., team, divisional, or center wide.

Supports the departmental educational and staff development initiatives including supervision of undergraduate/ graduate students enrolled in an accredited school of social work. As a field work supervisor, is responsible to Field Instructor/Liaison from the school of social work for evaluating student's performance and teaches the basics of medical social work and available community resources. Attends regularly scheduled departmental in-service presentations regarding new resources and clinical techniques.

Demonstrates skills and knowledge necessary to provide care appropriate to neonatal, pediatric, adolescent, adult, and geriatric patients, including knowledge of growth and development, the ability to obtain and interpret information to identify patient needs, and to provide the care needed.

Performs assigned work safely, adhering to established departmental safety rules and practices. Reports to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.

Performs other related duties as required.

EDUCATION AND EXPERIENCE REQUIREMENTS:

- Master's degree in Social Work (MSW) or Master of Social Services degree (MSS) from an accredited graduate school of Social Work.

- Licensed CSW or MSW as required by the state of Delaware no later than June 11, 2024.

- Acute Care Social Work experience preferred.

SPECIAL REQUIREMENTS:

CCM required within 18 months of eligibility