Ambulatory Social Worker - Ambulatory Care Transitions

Evaluates the psychosocial concomitants of illness and trauma, and provides social work services to patients and families to optimize their ability to benefit from treatment, cope with the realities of their medical condition, and participate in their care. Coordinates transitions of care for patients with high psychosocial needs. Develops and maintains current knowledge of and liaisons with local, state, and federal services that may provide education and resources to patients and families. Supports the efforts of HIM and Patient Accounts by ensuring timely, accurate, and complete data entry in multiple information systems/data bases. Ensures understanding through collaboration with Care Coordinator and other interdisciplinary team members for review of multidisciplinary plan of care in patient chart (estimated LOS, tentative discharge date, assessed needs for discharge, and plan discussed with patient/family). Ensures attendance at Multidisciplinary Rounds or Huddles and reports on psychosocial status and its implication for transitions of care. Monitors progress toward the goals of the social work plan of care and revises it in response to changes in patient needs and condition. Assesses any potential obstacles to successful reintegration into the community (clinical, social, support, home environment) and escalates through appropriate channels to resolution. Ensures post discharge continuing care plan is transferred to the next level of care and remains compliant with documentation policies. Responsible for performing job duties in accordance with mission, vision and values of Tampa General Hospital. Specialty areas of practice include Emergency Department, Transplant, Palliative Care, and Mental Health/Substance Abuse. Emergency Department social workers provide brief crisis counseling and therapeutic intervention with particular focus on frequent utilizers of the healthcare system. Post-discharge follow up phone calls are placed to high-needs utilizers of the ED in an effort to prevent readmission. Transplant, Palliative Care, and Mental Health/Substance Abuse social workers are members of a devoted, multidisciplinary consultative service. Social workers in these areas of practice see all patients for whom their team is consulted and round daily with the multidisciplinary team. Generally, the specialty area social worker will see a patient for whom he or she has been consulted in any subsequent admissions as well.

Qualifications

MSW degree from a C.S.W.E.-accredited college or university Social Work program. At least 2 years' experience in a health care facility or program. Advanced level of social work skill and experience necessary to manage the provision of discharge planning and social work services to patients with complex emotional, social and medical problems. Willing to commit to and comply with established quality and service standards of the hospital and department. Specialty areas of practice require Florida Licensed Social Worker (LCSW) and certification (as available) or pursuit of certification in that specialization, i.e. ACHP-SW, IC&RC ADC, CCTSW, or other. Social workers in specialty areas should prioritize continuing education pertinent to their area of specialization annually