Social Worker - St. Francis Cancer Center

Social Work Case Manager

At Bon Secours Mercy Health, we are dedicated to continually improving health care quality, safety and cost effectiveness. Our hospitals, care sites and clinicians are recognized for clinical and operational excellence.

The Social Work Case Manager (SW-CM) is a key contributor to the overall financial and customer satisfaction performance at St. Francis Cancer Center. The SW-CM is accountable for the development and implementation of supportive care plans for all patients seen at the St. Francis Cancer Center. Responsible for the timely coordination of case management services to assist individuals and their families in addressing social, emotional and economic stresses associated with illness or injury.

The SW-CM will support an outcomes oriented patient care delivery system, which places the patient at the center of all activities. The SW-CM will provide comprehensive clinical assessments and supportive treatment for oncology patients and families. Provide patients/families with concurrent information regarding diagnoses, treatment plans and discharge plans. Perform psychosocial assessments to identify high risk cases and initiate referrals to promote independence and the ability to care for oneself. The SW-CM may provide individual or group therapy to patients and families who are experiencing changes due to oncology diagnosis.

Employment Qualifications:

Education: Minimum of a Masters' degree from a school of social work or social welfare accredited by the Council on Social Work Education. Licensed by the South Carolina State Board of Social Work at the Licensed Independent Social Worker Clinical Practice/Advanced Practice level (LISW-CP/AP) or LMSW (Preferred). Minimum of three years' experience in social work activities in a medical setting preferred, minimum of three years' experience in social work counseling required.

Skills: Trained in the principles and practices of social work. Able to assess data reflective of the patient's status and interpret appropriate information needed to identify each patient's requirements for care relative to his or her age-specific and cultural specific needs. Knowledgeable of supportive care planning, including home health care, adoption, home bound schooling, placement in foster homes, assisted living, subacute, rehabilitation, hospice, and long term care facilities and all available community resources. Demonstrate the ability to counsel patients and families regarding financial assistance and community services. Knowledgeable of regulatory/accrediting agency requirements, including Child and Adult Protective Services and the Omnibus Adult Protection Act. Education and training to provide counseling support as needed.

Exhibit communication skills which encompass the ability to:

• Obtain and interpret information appropriate to patient age, cultural background and level of education and comprehension;
• Provide constructive feedback and convey a caring attitude;
• Coordinate care between clinical specialties, medical staff and community agencies for safe and appropriate supportive care planning;
• Coordinate care to support cultural, ethical and religious beliefs;
• Formulate and logically convey ideas while being sensitive to the needs and feelings of others; and
• Encompass critical thinking, decision making and the ability to help patients/families maintain independence for health care decisions.
• Demonstrate good to excellent computer skills and become proficient in navigation of the electronic medical record (ConnectCare).

Expected Behaviors:

• Respect Treat all people well because all people have dignity; makes people feel welcome; recognize other's point of view; responds to agreed upon time frames; show concern for one's impact on others; exhibit mutual appreciation and respect for one another; exhibit appropriate phone and email manners; is responsive; all speech is appropriate (no unfounded criticisms, no offensive comments, no public arguing, no gossiping); before speaking ask if words are true or false, exaggerated or accurate, healing or cutting, grateful or complaining?
• Justice Support, protect and promote the rights of all individuals and has a special concern for the poor and dying; raise issues/questions with the appropriate person; demonstrate concern for the rights of others; honor appropriate confidentiality; treat all customers and staff the same regardless of race, religion, ethnic background or socio-economic level; support privacy of others.
• Integrity Demonstrate honesty and truthfulness in all dealings; maintain and protect confidentiality of organization information at all times; carry out responsibilities consistently; honor commitments and keep promises; maintain appropriate relationships.
• Stewardship Dedicated to the responsible and creative utilization of our resources to assure the continuance of our mission; use time efficiently; respect other's time and resources; set appropriate priorities for own work and those led; match resources with the need; treat all organizational property and resources with respect and care.
• Innovation Continually search for new ways to profoundly improve our services; supports and is open to new ideas and approaches to meet people's needs; suggest new ways of doing things.
• Compassion Experience and express empathy with the life situations of others; give kindly care to all in focusing on the customer rather than the task; support others in need; serve others; listen actively and look directly at the person who is speaking; support others through changes that affect them.
• Quality Continually improve our system's processes of care and service to our patients, physicians, co-workers, and community through understanding needs and striving to exceed expectations; simplify systems; actively solicit opinions of others to improve the quality and value of services.
• Growth - Committed to the implementation of programs that inspire positive development in the organization, co-workers and community; is sensitive to the changes necessary to meet the challenge; identify strengths and assist in the development of others; seeks personal and professional development; offer to share knowledge and experience with others; think how work fits within the

Essential Job Functions:

Conduct an objective assessment of the patient's current health care status and document such in the patient's medical record, including a situational analysis and functional assessment covering elements such as:

• Reason for entry into the system;
• Physical condition;
• Age;
• Psychological assessment;
• Social/family assessment;
• Spiritual assessment;
• Financial assessment;
• Vocational assessment;
• Primary caregiver availability;
• Learning capabilities/self-care;
• Health status expectation; and
• Community reintegration potential.

Utilize data from the situational analysis, functional assessment, clinical review criteria and the electronic medical record (ConnectCare) to identify and prioritize patient supportive care needs. Participate with the development/expansion of the plan of care to encompass multi-disciplinary patient care needs, including participation in Acute Care Interdisciplinary care rounds when appropriate. Participate with the revision of the plan of care as appropriate and document any revision of the supportive care plan in the patient's medical record. Facilitate multi-disciplinary plan of care meetings to maintain rapport and communication with the treatment team to monitor and evaluate the plan of care and patient supportive care plan; identify/prioritize problems and make adjustments as required. In accordance with the South Carolina Social Work Practice Act (Title 40 Professions and Occupations, Chapter 63, Section 40-63-10 23-26) The Social Work Case Manager (LBSW, LMSW and LISW), according to the practice of "Case Management" may write physician telephone and/or verbal orders related to discharge planning to facilitate timely execution of the patient discharge/supportive care plan The Physician will co-sign all Social Work orders. All orders are to be entered into the electronic medical record ConnectCare. This will facilitate transition of Upstate Oncology patients between in-patient, out-patient and home care as appropriate to maintain pt in the least restrictive care setting to meet patient care needs. Demonstrate leadership by initiating referrals to community agencies as needs are assessed (Adult/Child Protective Services, Med Assist, American Cancer Society, DSS etc ). Set goals and time frames for achievement of goals that are appropriate to the patient, family, physician and other members of the health care team. Communicate patient care interventions in writing. Routinely evaluate progress towards the attainment of goals, and request Palliative Care intervention to assist with care management when appropriate to meet pt care needs. Maintain rapport and communication with the patient/family to provide concurrent information regarding diagnostic testing, treatment plans and supportive plans. If the prognosis is poor, or the patient is anticipated to be terminal, direct care towards maintenance of comfort and request palliative care intervention as appropriate and providing support and grief counseling as needed to patient and family. Utilize proactive triggers (diagnoses, readmission and patient satisfaction scores) to identify potential over/underutilization of services and make suggestions as appropriate. Promote prevention of hospitalizations/readmissions by linking the patient/family with the most appropriate institutional or community resources; develop new resources if gaps exist within the health care continuum. Provide communication and knowledge of benefits to patients and physicians before expenses are incurred. Educate hospital and medical staff regarding Case