Social Work Care ManagerBolingbrook, IL

Social Work Care Manager

UChicago Medicine AdventHealth Bolingbrook has been providing faith-based care in the Adventist tradition to Chicago's western and southwestern suburbs since 2008. The 138-bed medical center features an award-winning Level II trauma center and offers the latest advancements in medical technologies and care with private, family-friendly patient rooms and access to top doctors.

Every day, our fellow team members show up to work, unified by one shared mission: Extending the Healing Ministry of Jesus Christ. As a faith-based health care organization, our story is one of hope as we strive to heal and restore the body, mind and spirit. Though our facilities are spread across the country, this unwavering belief binds us together. Across every office, exam and patient room, we're committed to providing individualized, holistic care. This is our Christian mission, and it inspires us to help make communities healthier and happier.

Schedule: PRN days; 8:30am-5pm

Location: UChicago Medicine AdventHealth Bolingbrook Hospital, 500 Remington Blvd, Bolingbrook, IL

The role you'll contribute:

The Social Work Care Manager intervenes with patients who have complex psychosocial needs, require assistance with eligibility determination for social programs, funding sources and qualify for community assistance from a variety of special assistance programs and agencies, and/or require assistance with transitions of care or discharge planning. In addition, offer crisis intervention to patients and families with psychosocial needs and coordinates and facilitates the development of a discharge plan of care for high-risk patient populations. This role will receive referrals for individuals from at-risk populations from interdisciplinary team members (including physicians, RN Care Managers, staff nurses, and other members of the care team). The Social Work Care Manager, in collaboration with the patient/family, care manager nurses, nurses, physicians and the interdisciplinary team, ensures patient-centered care coordination through the continuum of care. The Social Work Care Manager ensures efficient and cost-effective care through appropriate resources monitoring and clinical care escalations.

The Social Worker is under the general supervision of the Care Management Supervisor or Manager and is responsible for patient evaluations of post-hospital needs; development of a transition of care plans and initiation of the implementation of the transitions of care plans prior to the discharge of the patient. The Social Work Care Manager is responsible for optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, readmission prevention and length of stay management. The Social Work Care Manager communicates daily with the interdisciplinary team during daily multidisciplinary rounds. Care coordination, discharge planning, transitions of care planning and are core competencies of this role. The Social Work Care Manager facilitates the collaborative management of patient care across the continuum, intervening to remove barriers to timely and efficient care delivery and reimbursement.

The Social Work Care Manager provides education to nurses, physicians and the interdisciplinary team on issues related to utilization of resources, medical necessity, CMS CoP for Discharge Planning and care coordination. The Social Work Care Manager is knowledgeable of post-hospital care and services available to the patient including, but not limited to the following: Home Health, Infusion Services, Durable Medical Equipment, Palliative Care, Hospice, Outpatient Services, Transitions of Care Clinics, Transitional Care supportive programs and clinics, follow up appointments, Skilled Nursing Facilities, Rehabilitation Services and Facilities and Community-based Organizations. The Social Work Care Manager adheres to departmental and system goals, objectives, policies and procedures and ensures quality patient care and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

The value you'll bring to the team:

Psychosocial Assessment and Interventions

o Assesses patient's and family's psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, assisting those coping with adjusting to significant life transitions

o Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability; accesses and mobilizes family/community resources to meet identified needs

o Serves as a resource to provide information and intervention related to treatment decisions, terminal illnesses and end-of-life issues

o Provides grief counseling and crisis intervention skills

o Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the healthcare system

o Provides de-escalation services for patient/family as appropriate

o Provide Motivational Interview techniques for patients with substance use and addictive disorders

o Provides patient/family education, adjustment-to-illness counseling, grief counseling and crisis intervention

o Provides education to patients/families/caregivers regarding resource options and coping with diagnosis, treatment and prognosis

o Works in collaboration with hospital and community agencies to obtain needed services and resources for patients/families/caregivers

Receives referrals for psychosocial complex needs from the health care team.

Provides assessment and reporting interventions in child abuse/neglect, domestic violence, adult/elderly abuse, child protection, sexual assault, and human trafficking as appropriate.

Provides consult services for patients who may possibly lack decision making capacity. Follows the guardianship (temporary/permanent) policies and procedures and coordinates with Care Management leadership throughout the process.

Provides consult services for foster care and adoptions.

Assists the health care team in the patient assessments and placements for mental health services.

Facilitates full team discussion including patient and family when ethical dilemmas arise.

Promotes the understanding and use of advanced directives and ensures patient preference and care goals are followed

Completes Initial Evaluation for transition of care needs on all identified patients within one calendar day of admission and documents according to policies and procedures. Interviews patient and involved care givers (as permitted by the patient) as well as a review of the current and past inpatient and outpatient medical record in the Initial Evaluation.

Reviews necessary patient information including labs, medications (Pre and post hospital), History and Physical, therapy notes, ED notes, test results and progress notes.

Incorporates the patient/family care goals and preferences as much as possible into the transition of care planning and communicates these goals and preferences to the multidisciplinary team.

Incorporate clinical, social and financial factors into the transition of care plan.

Meets with patient/families to discuss realistic and appropriate discharge options and providers of post-hospital care.

Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to meet the individual needs of each patient

Identifies and collaborates with the interdisciplinary team and hospital operations to resolve potential barriers to transition of care plan achievement.

Collaborates with the multidisciplinary healthcare team daily in multidisciplinary rounds to efficiently communicate and facilitate high quality patient progression of care and transitions plans.

Evaluates the potential for readmissions throughout the patient stay through the monitoring of each patient's readmission risk scores and coordinating readmission mitigation interventions.

Assures Social Work consults are completed for specialty services related to psychosocial needs, decision making needs for patients who lack capacity, patient/family adjustment needs and psychosocially complex cases.

Develops discharge plan with appropriate contingency plans throughout the hospital stay to enable adaptation to evolving patient care needs and ensure timely care coordination.

Escalates issues barriers to appropriate level of Care Management leadership

Assists with End of Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR.

Facilitates patient care conferences with multidisciplinary team as needed.

Establishes and documents, based on the predicted DRG and multidisciplinary team member's input, Anticipated Date of Transition (ADOT) and destination and updates, as needed.

Actively participates in daily Multidisciplinary Rounds to review progression of care and discharge plan for all assigned patients

Proactively identifies patients who no longer meet medical necessity and escalates potential denials, documents avoidable days, and facilitates progression of care.

Collaborates with Utilization Management staff for collaboration on patient status changes and medical necessity discussions.

Ensures all patients on assigned unit(s) are moved timely and effectively to appropriate levels of care

Ensures reassessment of discharge needs provided anytime a patient's condition changes and/or the circumstances impacting the provision of post-hospital care changes.

Ensures patient notifications are provided and documented in a timely manner for compliance: Important Medicare Letters (IML), Medicare Outpatient Observation Notice (MOON), Patient Choice, and Beneficiary Notice Letter (BNL).

Communicate with patient/family the possible need to pay for services out of pocket.

Ensures primary care physician identification and scheduling of follow-up PCP and specialist