Social Worker, Scranton Transitional Rehab Unit (Call In)

GENERAL SUMMARY:

Under the direction of the Director of Social Services, the Social Worker aids residents and their families with personal and environmental difficulties which predispose illness or interfere with obtaining maximum benefits from medical care.

The Social Worker must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the residents served by his/her department—adult through geriatric.  The Social Worker must demonstrate knowledge of the principles of growth and development over the life span; possess the ability to assess data reflective of the resident's status; interpret the appropriate information needed to identify each resident's requirements relative to their age-specific needs; and to provide the care needed as described in the Social Service Department's policies and procedures.

Type of supervision exercised: none.  Jobs reporting to this position: none.

EDUCATION:

Bachelor’s degree in Social Work or related field required.

Master’s degree in Social Work or related field preferred.

WORK EXPERIENCE:

Minimum of two (2) years of experience in a Social Work Department health care setting required.

CHARACTERISTIC DUTIES & RESPONSIBILITIES OF JOB:

• 25%  Performs the duties of Resident Advocate as follows: 

Ø Acts as primary resource to receive and respond to resident/family questions and concerns.  Investigates and follows-up on complaints which relate to roommate incompatibility and missing personal items/clothing.  Follow-up and document all resident/family complaints to determine satisfaction.

Ø Interviews residents and/or family members in any allegations of abuse, neglect or misappropriation of property, ensuring accurate documentation for Department of Health reporting requirements.

Ø Plans and implements room changes to accommodate resident individual requests, the need for movement to appropriate care unit, admissions bed management, and infection control issues.  Communicate changes to residents and roommates and documents same.

Ø Facilitates an interdisciplinary approach to bed management.  Plans and implements room changes to accommodate resident requests or for admissions bed management. Communicates changes to residents, units and admissions

Ø Facilitates acquisition of services, such as; Home Health or Outpatient Therapy referrals, and durable medical equipment referrals.

Ø Communicates changes in financial coverage relative to discontinuance of Medicare/Commercial Insurance coverage to residents and families and facilitates decision-making on new payer sources.

· 23%  Performs Social Work Admissions Assessment on each new resident.  Identifies current status, discharge plans and initiates care plan. Prepares and keeps updated a case record for each resident including pertinent diagnoses, mood, behavior and psychosocial issues.  Documents resident’s condition upon returns f rom hospital facilities. Responsible for completion of chart progress note requirements related to Resident Assessments per Medicare  mandated schedules.  Continuously evaluates data and plans care management strategies on behalf of residents.  Follows medical recommendations and provides service planned to restore residents to optimal social and health adjustment.  Advises residents, families and facility staff on social problems of the residents and develops approaches to minimize effect on resident quality of life.  Participates with other members of the interdisciplinary team on resolving problems that relate to the resident’s disability. Conducts individual or group conferences for residents/families, as needed.

• 9%  Responsible for completion of assigned Minimum Data Set sections of resident assessment instrument to comply with regulatory requirements on a timely basis.  Performs seven day daily chart documentation on every resident scheduled for care plan review.

· 9%  Develops Social Work portion of multi-disciplinary care plans, and consistently updates for mood, behavior and psychosocial well being changes.  Coordinates same with all other applicable disciplines.  Attends care plan meetings for residents.  Initiates invitations to  care plan meetings for all involved residents and families, coordinates scheduling of attendance at care plan meetings. 

• 4%  Provides supportive counseling to residents who refuse care or treatment or who wish to discharge AMA, develops alternatives that incorporate resident individual preferences whenever possible, and educates resident and/or family to risks and benefits of their care decisions.
• 27% Coordinates resident discharge from the facility.  Routinely communicate with external community agencies and resources to facilitate discharges to home and ensure care needs are met.  Organizes and facilitates discharge planning meetings, reviewing multi-disciplinary discharge instructions.
• 1%  Reviews Code status and Forms of Treatment for resident per physician and/or nursing request.  Contacts all appropriate family members to facilitate changes, as per policy.
• .5%  Participates in educational programs.
• .5%  Provides all residents with the opportunity to keep valuables locked in nightstand.  Dispenses key and retrieves key when necessary.
• .5%  Communicates changes in guardianship or power of attorney status to appropriate disciplines.
• .5%  Acts as witness to petty cash disbursements weekly with Resident Trust Clerk.
• .5%  Obtains resident signatures to authorize release of information.