Social Worker I – Transplant – Houston, TX

• Communicates in an active, positive and effective manner to all health care team members and reports pertinent patient care and family data in a comprehensive and unbiased manner; listens and responds to the ideas of others. Uses therapeutic communication to establish a relationship with patients and families and communicates the discharge plan, facilitating transitions and hand-offs. Supports patients and families in clinical or ethical issues.

• Uses patient and family-centered approach in collaboration with interprofessional health care team. Facilitates discharge planning activities for assigned patients and collaborates with the case manager and other members of the interprofessional health care team, as well as patient and family. Maintains ownership of the psychosocial component, assessments, diagnosis and treatment, of the discharge planning process on assigned units.

SERVICE ESSENTIAL FUNCTIONS

• Serves as a unit-based participant for comprehensive case management activities including assessing patients and collaborating with team to identify at-risk patients, participating in daily Care Coordination Rounds, and identifying any barrier(s) of efficient patient throughput.

• Develops and implements a comprehensive psychosocial treatment plan utilizing appropriate clinical social work diagnoses, treatments and interventions, including crisis intervention, brief individual, marital and family therapies, and patient, family and caregiver groups. Assists with screening, identification, diagnosis, management and treatment of victims of abuse, neglect, and domestic violence and of mental health and/or substance abuse problems in patients and family members.

• Completes a full assessment based on the social work assessment, identifying social determinants of health. Completes screening by patient/family interview, review of the medical record including previous episodes of care, H&P, lab and other test results/findings, plan of care, physician orders, nursing and progress notes. Uses clinical knowledge and screening tools to identify need for case management and/or social work intervention.

• Establishes mutual educational goals with patient and family, provides appropriate resources, incorporating planning for care after discharge.

• Uses knowledge of levels of care, working with patient and family, to ensure discharge disposition is to the appropriate level and facilitates transfers. Provides brief, goal-directed counseling services to assist patients/families to cope more effectively with the transition.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Modifies care based on continuous evaluation of the patient’s condition, using problem-solving and critical thinking, and makes decisions using evidence-based analytical approach. Documentation reflects completed patient screening/assessment and reassessment upon admission and concurrently, as needed. Considers variables that impact treatment plans including diagnosis of emotional, social, and environmental strengths and problems related to their illness, treatment and/or life situation.

• Continuously reviews the patient for opportunities for care facilitation and needs for discharge planning. Works with case manager for routine discharge and anticipates/prevents and manages/elevates emergent situations with specific focus given to discharge plan and elimination of psychosocial barriers.

• Collaborates with staff from the interprofessional health care team concerning safety data to improve outcomes and the safe transition of care through effective patient handoffs

FINANCE ESSENTIAL FUNCTIONS

• Completes timely and thorough assessment on all unfunded patients to identify community resources required for effective transition and able to utilize alternative resources to fill gaps in established community resources.

• Establishes an effective community resource knowledge base and the judgment/ability to effectively select and coordinate available resources, including referrals to regulatory agencies, i.e. CPS/APS.

• Provides timely, efficient pertinent patient information to healthcare team when coordination with significant or intensive resources is necessary for effective discharge planning outcomes and decreased length of stay.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Provides education to unit-based physicians, nurses, and other healthcare providers on community resources and psychosocial impact on care needs.

• Identifies areas for improvement based on understanding of evidence-based practice literature. Assists in evidence-based practice/performance improvement projects based on observations by offering solutions and participating in unit projects and activities.

This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

• Master Degree in Social Work

WORK EXPERIENCE

• 0 years of experience

• New graduate with hospital internship preferred

• One year hospital social work experience preferred