Under general supervision 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. Demonstrates positive interpersonal relations with patients, families, visitors, and co-workers in accordance with UMMS and departmental policies and procedures. Through advanced practice skills mobilizes resources to reduce risk, and serves as ambassador between hospital and community.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

• Assess the patient's psychosocial situation in relation to the medical and psychiatric needs by providing brief admission assessments of each patient, family, or significant other to extend support and determine willingness. Ability to understand and comply with the D/C treatment plan, and understand availability of the caregiver to care for the hospitalized patient upon discharge.
• Interviews patients, family members, and/or significant others identified through case finding or referral to assess needs for social work services and plans appropriate interventions and treatment goals to improve psychosocial outcomes.
• Reviews patient chart and nursing care plans for pertinent medical care or nursing care information.
• Provides preventive, protective, or supportive services, including mandatory reporting for patients who are in or who are threatened by situations detrimental to their well-being.
• Interprets psycho-social services programs and procedures to client, staff and community organizations.
• Works with the Care Coordinator and the treatment team to develop a safe and timely discharge plan A and B that complies with regulations and laws regarding patient and family wishes. Responsible for mental health placements, homelessness plans, pharmaceutical plans, guardianship procurement, residential care, other psycho-social related placements and hospice/palliative.
• Ensures continuity of care throughout the continuum of care when required by patient population.
• Identifies the need for and conducts family meetings that result in comfort, decisions, and other important outcomes.
• Leads or co-leads Care Coordination Rounds
• Independently diagnoses and treats psychosocial and emotional conditions using evidence supported approaches and appropriate modalities in order to remove barriers to health care and/or discharge planning and post discharge compliance with the treatment plan.
• Provides consultation to LGSW staff on difficult psychosocial cases.
• Conducts comprehensive psychosocial evaluations and 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.
• Maintains confidentiality in accordance with hospital and departmental policy and professional standards. May accompany patients to obtain benefits, entitlement or other services.
• 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.
• Helps create function and productivity on the many teams to which the SW belongs, facilitating the resolution of conflict in order to present a united message to patients and families.
• Demonstrates a commitment to professional development through participation in relevant in-service and continuing educational programs.
• Actively examines clinical practice and seeks self improvement through use of supervision, peer consultation, or other methods to develop therapeutic knowledge and skills.
• Participates in the training and education of allied health professionals in the hospital and/or in the community.
• May participate in the clinical teaching and instruction of undergraduate or graduate social work interns in the field of practice.
• Participate in research and publication activities, as needed.
• Actively participates in clinical performance improvement activities.