Social Worker Team Leader

Job Description Summary

Under the general supervision of the Care Progression Manager, the Social Worker Team Lead will assist the Manager in the day-to-day operations of Social Work with training and mentoring for all Clinical Social Workers at South Shore Health. Provides patient focused psychosocial assessment as well as implementation of ongoing discharge planning, and coordination of care that supports quality, utilization, and cost of care and operations. Act as a resource for all Clinical Social Workers and Care Progression Department. Works in coordination with the RN CASE MANAGER to coordinate, negotiate, procure services and resources for and manage the transitional care planning of patients to facilitate achievement of quality and cost efficient patient outcomes.Responsible to work with a multi-disciplinary patient care team to optimize the discharge planning mission for patients, from admission to discharge, which requires varying degrees of follow-up and follow through, including fostering, executing, and expediting and efficient and effective discharge process.Works collaboratively with the interdisciplinary staff internal and external to the Organization. Participates in quality improvement and evaluation processes related to the management of patient care.

Job Description


Job Responsibilities:

1 - As team lead, provides frontline support and oversight of assigned staff.
a - Will orient new staff to SSH&EC following orientation/competency checklist.
b - Meets monthly or as needed with assigned staff to discuss specific patient problems, to develop and refine clinical skills, to promote professional development, to provide feedback
c - Develops orientation goals/objectives with each new staff member to promote maximum productivity, proficiency and professional growth
d - Acts as a resource to staff in areas of patient care and organizational policies and procedures.
e - Promotes effective communication as staff liaison re: clinical and operational matters.
f - Reports to Care progression Manager any concerns brought forward by Social Work team.
g- Update daily assignment reflecting schedule changes due to sick calls or acuity of assignments
h - Ensure all shifts on schedule are covered (weekday/weekend/holiday)
i - Assists Care progression Manager in interview process for hiring of new staff.
j. -Supports LCSW to obtain LICSW by providing supervision hours

2 - Functions as a role model for current and new staff.
a - Accepts assignment as preceptor for new staff
b - Facilitates problem resolution among peers as observed by Manager.
c - Initiates department projects as they relate to Social work role and process.

3 - Demonstrates leadership behaviors in a professional manner.
a - Communicates in a constructive manner with colleagues to decrease conflict and promote teamwork.
b - Recognizes and explores own impact on others.
c - Utilizes problem-solving techniques to prevent conflict and promote team development.
d - Demonstrates initiative in pursuing own professional development.
e - Guides and assists other staff members in growth and development; i.e., resource, preceptor, role model, conducts conference.
f - Coordinates in-service identified in need assess

4 - New Admissions
a - Review work list/census to prioritize patients and identify those that meet criteria for social work interventions
b - Review referrals received via:

• Physician

• Nursing or ancillary staff

• Patient and family

c - Initiate referrals from Case Manager (CM) or self-referral when appropriate
d - Complete initial psychosocial assessment/Initial Discharge Planning Assessment to evaluate and document patient needs and resources.
e -If discharge plan initiated, verify demographics and insurance information is correct
f - Coordinate with CM to develop post-acute discharge plan.
g - Complete and document initial discharge planning or psychosocial assessment if required in Electronic Medical Record (EMR) on identified patients within 24 hours of patient admission/one business day or within 24 hours of referral
• Begin discharge planning discussions with patient/family

5 - Urgent Referrals
a - Respond to and prioritize urgent high-risk cases such as
• Crisis interventions
• Adult Protective Service (APS) and/or Child Protective Service (CPS) referrals
• Guardianship referrals
b - Coordinate appropriate community and resource specific referrals
• Financial
• Educational
• Counseling/family support agencies

6 - Discharge/Transition Planning
a - Initial assessment/screening and evaluation of patient and families
b - Reassess the discharge plan to determine post-acute discharge needs (a minimum of every three days or as condition or plans change) and communicate with patient/family/care team on an ongoing basis
c - Identify required authorization for post-acute services and refer to the appropriate post-acute provider
• After initial assessment complete, a discharge plan should be developed with the care team so post-acute arrangements can be made as soon as possible
• Identify potential alternative levels of care
• Post-acute plans
• Long-Term nursing home placement
• Skilled Nursing Home placement
• Outpatient Services
• Ensure that patient has received all information related to choice of follow-up care facilities, and/or public or private care providers, including explaining all elements of discharge, continuum of care needs and available options to patients, families and/or care givers and document
• Identify patient's readiness to discharge based on discussions with the patient/family/care team members during interdisciplinary rounds
• Treatment options as well as consequences of various treatments or treatment refusal
o Assist patients/families with adjusting to hospital admission; possible role changes; exploring expediting responses from provider facility personnel as necessary.
d - Document response by providers
e - Delivers the Medicare Important Message (IM) per department protocol.
f - Have patient, family/healthcare Proxy sign discharge plan.
g - Ensure that discharge plan is confirmed and address any barriers
• Finalize details with interdisciplinary care team during interdisciplinary rounds (IDR) and patient/family the day prior to discharge
h - Arranging for resources/funds to finance medications, durable medical equipment, and other needed services
i - Ensure that discharge plan is confirmed and address any barriers
• Finalize details with interdisciplinary care team during Interdisciplinary Rounds (IDRs) the day prior to

7 - Interdisciplinary Rounds
a - Attend and actively participate in IDRs as assigned
b - Report during IDRs
• Psychosocial barriers to discharge
• Resource limitations
• Anticipated discharge plan
• Patient/family concerns
• Follow-up items for SW/CM
c - Make sure projected discharge date is accurate
d - Document avoidable delays identified during IDRs

8 - Clinical High-Risk Meeting
a - Attend and actively participate in weekly clinical high risk (CHR) Meetings
• Discuss any high-risk cases not identified by CHR criteria (e.g., LOS)
b - Complete any CHR assigned follow-up items after the meeting and document
c - Follow formal escalation process for any patient identified for escalation

9 - Communication and Coordination
a - Communicate with care team (Physician, Provider, Nursing Staff, Ancillary) about identified psychosocial issues or barriers that might delay or prevent timely discharge
b - Update CM counterparts/care team regularly
c - Collaborate with internal team and external agencies to coordinate care and timely discharge:
• Facilitate patient care conferences and patient /family meetings
• Coordinate with outside agency personal and assist with meetings
• Coordinate with legal system (guardianship/adoption)
d - Ensure patient/family is updated and involved in the care plan

10 - Escalation
a - Escalate to Case Management leadership using chain of command
b -. Escalate all high-risk cases that will require additional attention or resources in order to remove risks and barriers to a timely discharge

11 - Regulatory Requirements
a - Understand Joint Commission, everyday readiness, emergency preparedness plans and department downtime processes.

JOB REQUIREMENTS

Minimum Education - Required

BS in Social Work, Master's prepared LICSW. Demonstrates competency in basic computer and keyboard skills required, knowledge of basic medical terminology, EPIC and Outlook preferred.

Minimum Work Experience

Recent healthcare experience or related field preferred. Hospital Social Work experience preferred. Experience working with patients and families, elders and their caregivers, and/or various other community populations desirable.

Licenses / Registrations

LICSW - Licensed Independent Clinical Social Worker

Required additional Knowledge, and Abilities

Demonstrated Leadership skills, Team building, commitment to education, promoting continuous quality improvement, creative problem solving and critical thinking. Excellent communication skills required: ability to work independently and under very stressful situations required. Ability to time manage, set priorities and self-origination will be essential to success of employee. Ability to work within a multidisciplinary team and in collaboration with the RN Case Manager.