LEAD SOCIAL WORKER – DISCHARGE AND CLINICAL SOCIAL WORK

Will deliver and manage excellent services and systems of care for persons with serious mental illness.

The Social Worker provides general casework services to assigned patients and their families. Maintains overall responsibility for appropriate discharge planning and utilization reviews for existing patients.

POSITION OVERVIEW

This position provides both the discharge and clinical responsibilities of a psychiatric lead social worker. He/she is responsible for completing all the social work documentation including psychosocial assessments, individualized plan of care, on-going coordination and facilitates discharge planning to patients. Meets documentation requirements and functions as a member of the interdisciplinary team. The position also facilitates 1-2 discharge planning or process group a week.

• Bachelor’s degree in social work, required
• Minimum of five (5) years’ experience with social work and discharge planning
• At least two (2) years geriatric social work
• Exemplary interpersonal skills and ability to work cooperatively as a member of interdisciplinary team
• Ability to communicate empathically, respectfully and effectively with patients and their families
• Effective time management skills to organize and prioritize workload
• Understanding of Medicare guidelines, Title 22 regulatory requirements
• Knowledge of DSM/ICD and other medical terminology
• Familiarity with behavioral health resources in the community is desired.
• Successful completion of applicable background checks is required.

• 
  Assessment / Reassessment: completes an initial psychosocial and chemical dependency assessment within 72 hours of admission. Documents individual/group interventions daily in the medical record. Completes progress notes including psycho-social reassessment weekly or more often as needed.
• Treatment Planning: Assures that treatment plans include appropriate social service interventions within 72 hours and are updated with each change of behaviors and at least weekly.
• Interdisciplinary Team (IDT): Actively participates in the daily IDT process and is prepared for the presentation of pertinent information during IDT including revisions of treatment plans, behavior interventions etc. Assures that the interdisciplinary treatment plans are developed in collaboration with the psychiatric team, the patient and the patient’s authorized representative.
• Documentation: Writes progress notes on admission, weekly and as needed with new concerns, significant change of behaviors, responses to interventions and when new interventions are needed as well as discharge plans. Completes daily documentation of individual and group interventions.
• Patient teaching: instructs patients authorized representatives, conservator regarding treatment plans, discharge planning, achieving target behaviors, treatment and rehabilitation goals and aftercare treatments.
• Patient safety Goals: Participates in patient safety goals including but not limited to:

• Maintaining safe environment- participates in unit safety rounds
• Fall precautions
• Elopement precautions
• Assault precautions

• Acts as patient advocate: Ensures that mentally ill patients maintain their statutory and constitutional rights through patient advocacy and strong knowledge of Lanterman-Petris-Short (LPS) Act. Present cases in the 5250 involuntary hearing conducted by the county superior judge.

• Demonstrates the Verity mission, purpose, values and beliefs in everyday language and contact with patients, the public and other staff members.

• Provides safe, effective and efficient implementation of direct care in accordance with established policies, procedures and standards of care.
• Establishes and maintains a therapeutic relationship with patients and their families.
• Attends and participates in primary therapy, community meetings, family therapy, and groups.
• Assumes overall responsibility for discharge planning, including:

• Assessing the patient’s readiness for discharge in coordination with the Treatment Team.
• Making appropriate referrals for placement, case management and aftercare services, as assigned.
• Developing and maintaining an awareness of community resources.

• Provides consultation to patients and their families regarding issues arising from the admission, discharge and/or aftercare plan.
• Provide direct treatment for assigned patients and families.

• Participates as a team member and provides input via reporting observations, concerns and asking appropriate questions.
• Reviews and implements patient treatment plans.
• Actively facilitates and participates in multidisciplinary team meetings and treatment planning meetings.
• Demonstrates knowledge of management of assaultive behavior techniques.
• Provides leadership in facilitating the team process.
• Provides education/training to other team members as necessary.

• Observes, records and reports patient social and psychiatric behavior.
• Completes the Psychosocial Assessment for assigned patients. This includes obtaining necessary data regarding the patient’s social and psychological history.

• Demonstrates knowledge and proper use of equipment and supplies.
• Promotes and assists residents in developing self-help skills.

• Demonstrates a good rapport and cooperative working relationships with all members of the team; responds to co-workers with concern and promotes group morale.

• Continually focuses on assigned tasks and seeks and implements improvements as necessary.
• Understands and demonstrates the safety program in all activities.
• Protects residents from behavior that could damage themselves or others.
• Practices universal precautions at all times.

PLANNING AND TIME UTILIZATION

• Completes and follows through with tasks and assignments, meeting expected deadlines.

• Understands and demonstrates knowledge of all policies associated with attendance.

• Attends all assigned in-service education classes.
• Role models excellent professional practice.
• Always dresses appropriately and professionally.

• Coordinate with inter-disciplinary team, patients, families and community resources in provision of social and discharge services.
• Presents cases in the 5250 involuntary hold hearing conducted by the San Mateo County Judge.
• Work closely with department director, psychiatric medical director, and all clinical staff to meet the psychosocial needs of patients and families.
• Helps with the concurrent utilization reviews with out-of-network insurances.
• Complete comprehensive psychosocial assessment of patients in timely manner.
• Coordinate discharge planning, work as a liaison between the patients, their family, other department and community referrals.
• Responsible for the mandated fire arms reporting to the California Department of Justice on admission for patients’ subject for reporting.
• Coordinates discharge planning, assists with advance directives, financial and legal issues and maintains documentation of services in the medical record.
• Provides process group and individual counseling.
• Participates in formulating and updating care plans, development of goals and treatment plans.
• Maintain an accurate and timely documentation which complies with federal/state regulations and Seton Medical center policy including but not limited to Initial assessments, Psychosocial/Mental Status Assessments, Weekly IDT, Care Plan, Social Services Progress Notes and Discharge Planning.
• Act as a patient advocate and ensure they are informed of their rights, responsibilities and insurance benefits, as well as changes that may affect their rights, responsibilities and insurance benefits.
• Provides/facilitate individual counseling to patients and families as needed.
• Assists physician with completion of legal paperwork/documentation, mindful of individual county time constraints
• Participates in the unit QAPI and safety improvement projects. Reviews indicators for social services on a pre-assigned basis, makes necessary corrections and makes recommendations for improvement.
• Assist patients with coordination of complaint/grievance/compliment process. Follows facility policy and procedure and coordinates with program director.
• Complete timely assessments and treatment planning
• Performs other duties as assigned.
• Participates in the theft and loss program. Implements remedial actions as indicated.

• 
  Normal or corrected near and far vision, in addition to non-inhibiting color vision.
• May read constantly for short durations throughout the day
• Constant talking and hearing throughout the work day. Must be alert to patient condition and environmental situations.

NOTE: This job description is not intended to be all-inclusive. Employee may perform other related duties as negotiated to meet the ongoing needs of this organization.

I have read and understand terms and conditions of this job description. I further understand that by signing my acceptance of this agreement, it does not change the “at will” nature of my employment, which may only be altered through written notification signed by the CEO of Seton Medical Center and myself.

ACCEPTED AND AGREED:

_______________________________ ______________________

Employee Signature Date

_______________________________

Print Name