Social Worker II PRN | Skilled Nursing

Social Worker II Prn

At Houston Methodist, the Social Worker II PRN position comprehensively provides compassionate, clinical social work, psychosocial assessments, diagnosis and treatments, and complex discharge planning to patients and their families of a targeted patient population on a designated unit(s). In collaboration with physicians and the interprofessional health care team, this position sensitizes other health care providers to the social and emotional aspects of a patient's illness to collaboratively facilitate efficient quality care and achievement of desired treatment outcomes and affect positive patient and family outcomes. This position uses case management skills to help patients and their families address and resolve the social, financial and psychological problems related to their health condition. The SW II PRN position holds joint accountability with case manager, assuring that psychosocial and continuing care issues are addressed and treated as needed across the continuum of care and has responsibility for unit or departmental social work program development. This position serves as a hospital-wide, service-line leader for psychosocial related issues, complex discharge planning activities, and population disease management.

Patient Age Group(s) and Population(s) Served

Refer to departmental "Scope of Service" and "Provision of Care" plans, as applicable, for description of primary age groups and populations served by this job for the respective HM entity.

Houston Methodist Experience Expectations

Provide personalized care and service by consistently demonstrating our I CARE values:

Integrity: We are honest and ethical in all we say and do.

Compassion: We embrace the whole person including emotional, ethical, physical, and spiritual needs.

Accountability: We hold ourselves accountable for all our actions.

Respect: We treat every individual as a person of worth, dignity, and value.

Excellence: We strive to be the best at what we do and a model for others to emulate.

Practices the Caring and Serving Model

Delivers personalized service using HM Service Standards

Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)

Intentionally collaborates with other healthcare professionals involved in patients/customers or employees' experiential journeys to ensure strong communication, ease of access to information, and a seamless experience

Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

Actively supports the organization's vision, fulfills the mission and abides by the I CARE values

Responsibilities

People Essential Functions

Role models communication 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.

Provides staff education specific to patient populations and departmental processes. Functions as a preceptor and mentor to new employees. Identifies opportunities for professional growth of self and peers.

Service Essential Functions

Serves as a hospital/post acute-based leader for comprehensive case management activities including assessing high-risk patients and leading team to identify at-risk patients, participating in daily Care Coordination rounds, and identifying and leading resolution to barriers of efficient patient throughput. Completes a full assessment based on the social work assessment, leading and addressing solutions of social determinants which is accomplished 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 advanced knowledge and clinical expertise and screening tools to identify need for case management and/or social work intervention.

Addresses and manages conflict associated with 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. Maintains ownership of the psychosocial component, assessments, diagnosis and treatment, of the discharge planning process on assigned units. 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.

Establishes mutual educational goals with patient and family, providing appropriate resources, incorporating planning for care after discharge. Provides education to physicians and other interprofessional health care team members on mutually identified goals of care and uses knowledge of levels of care, working with patient and family, to ensure discharge disposition is the appropriate level and facilitates transfers.

Uses knowledge for different 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

Consistently documents to reflect completed patient screening/assessment and reassessment upon admission and concurrently as needed. Modifies care based on continuous evaluation of the patient's condition, demonstrates problem-solving and critical thinking, and makes decisions using evidence-based analytical approach. 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.

Consistently reviews the total picture of 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 by demonstrating an effective community resource knowledge base and judgment/ability to effectively select and coordinate available resources, including referrals to regulatory agencies, i.e. CPS/APS.

Identifies, obtains and utilizes alternative resources to fill gaps in established community resources.

Guides discharge planning activities for assigned patients and collaborates with the case managers and other members of the interprofessional health care team, as well as patient and family by intervening and coordinating cost-effective, complex discharge planning outcomes and decreased length of stay.

Growth/Innovation Essential Functions

Provides education to hospital 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. Completes and updates the individual development plan (IDP) on an on-going basis.

Identifies, initiates and leads 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.

Qualifications

Education

Master's degree in social work from accredited university

Work Experience

Three (3) years social services experience in a healthcare setting

License/Certification

Licenses and Certifications - Required

LMSW - Licensed Medical Social Worker - State Licensure AND Magnet ANCC-recognized Case Management certification

Ksa/Supplemental Data

Knowledge, Skills, and Abilities

Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations

Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security

Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles

Knowledge of community resources and health care financial and payer issues, and eligibility for state, local and federal programs

Maintains individual competencies around critical Social Work functions including; payor rules and regulations, psycho-social assessments and discharge planning methods

Ability to work independently and exercise sound judgment in interactions with physicians, payors, and patients and their families

Well versed in computer skills of the entire Microsoft Office Suite (Access, Excel, Outlook, PowerPoint and Word)

Critical thinking, collaboration, negotiation, and mediation skills

Time management and prioritization skills

Adherence to the clinical practice standards set forth by NASW practice standards for healthcare settings and more specifically