To assist patients and families to identify social, emotional, and environmental needs and to connect them with available resources/ services through the provision of a full spectrum of discharge planning and social work services.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
Works with the patient, family, and other members of the team to formulate a care plan that provides the client services in the appropriate setting. Gathers and assesses information regarding the client's physical needs, mental status, support system, financial resources, and available community and governmental resources. Employs assessment skills to develop a comprehensive case management plan that will address the needs identified.
Determines specific objectives, goals, and measures that are designed to meet the client's needs that have been
identified through assessment. The plan will be action- oriented and time-specific including collaboration with
community services. Maintains contact with the client's support services and insurance to ensure the most cost-effective plan of care is being carried out and appropriate service providers are being utilized.
Provides information about resources and options available in the community and coordinates service delivery.
Interprets patient/family needs and provides information concerning the availability and limitations of resources.
Educates and addresses concerns with service delivery including service gaps and access issues. Implements
care management plan through service referral and coordination activities. The Social Worker always assures that the patient is given the choice regarding agencies and services.
As part of the care management plan development process, collaborates with other healthcare and community service professionals.
Screens high-risk patients and consults with community and healthcare agencies regarding potential care planning problems identified as a result of this process. Interviews and assesses referred and high-risk patients to determine the need and desire for social work services.
Provides information based on current knowledge, to provide psychosocial support and assist the client in coping with their healthcare issues to improve their overall health care management.
Provides specific information on how to communicate with physicians and other healthcare staff to better utilize medical resources and increase understanding of the disease process.
The Social Worker will organize, secure, integrate and modify the resources necessary to meet the goals stated in the care plan. The Social Worker will monitor patient care
across the continuum through follow-up with clients, families, and community/ healthcare services.
Educates the client and their support system regarding various symptoms and consequences related to specific diseases, conditions and needs. This information will also include specifics regarding methods of professional intervention and description of the process of social work intervention in a medical setting and with Social Determinants of Health.
Represents the client by intervening, negotiating and promoting their concerns. Problems requiring advocacy may include individual and class inequities or inadequate and non-existent healthcare and/or community resources, i.e., insurance benefits, housing, etc.
Functions as consultant/advisor to program administration, utilization review, public and private insurance programs when care planning or resource issues occur. Keeps administration informed of changes in community, state, and federal policies that impact available resources.
Maintains pertinent and timely documentation in client's medical records and departmental records.
Collects and maintains specific information required for performance improvement indicators and research projects as required.
Performs client evaluations and histories. Provides psychosocial support through individual or family counseling, as needs dictate. Continuously reviews service area for needs and opportunities.
Represents ChristianaCare, when requested, through participation on committees, court hearings, referrals to community agencies, etc.
Attends regularly scheduled staff meetings, i.e., team, divisional, or center-wide as required.
Participates in professional activities to support social work services after having at least one year of service. May elect to participate in a departmental or program committee.
Supports the departmental educational and staff development initiatives. May elect to supervise undergraduate students enrolled in an accredited school of social work. As a field work supervisor, is responsible to Field Instructor/Liaison from the school of social work for evaluating student's performance and teaches the basics of medical social work and available community resources. Attends regularly scheduled departmental inservice presentations regarding new resources and clinical techniques.
Demonstrates skills and knowledge necessary to provide care appropriate to neonatal, pediatric, adolescent, adult, and geriatric patients , including knowledge of growth and development, the ability to obtain and interpret information to identify patient needs, and to provide the care needed.
Performs assigned work safely, adhering to established departmental safety rules and practices. Reports to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.
Performs other related duties as required.
EDUCATION AND EXPERIENCE REQUIREMENTS:
Bachelor's Degree in Social Work from a college or university accredited by the Council of Social Work Education required.
Two years of social work experience required.
Experience in assessing, developing, implementing, monitoring, and evaluating options and services to meet an individual's human service needs.
Community visits as needed
Internal Number: JR52205
About Christiana Care Health System
Christiana Care Health System is headquartered in Wilmington, Delaware and is one of the country's largest health care providers, ranking 21st in the nation for hospital admissions. Christiana Care is proudly a Nurse Magnet recognized institution. Christiana Care Health System is also one of the largest health care providers in the mid-Atlantic region, serving all of Delaware and portions of seven counties bordering the state in Pennsylvania, Maryland and New Jersey. A not-for-profit, non-sectarian health system, Christiana Care includes two hospitals with more than 1,100 patient beds, and is a major teaching hospital with two campuses. Christiana Care is continually recognized for excellence on a regional and national level. Our role in the community is expressed in the Christiana Care Way: "We serve our neighbors as respectful, expert, caring partners in their health. We do this by creating innovative, effective, affordable systems of care that our neighbors value."Christiana Care is a great place to work because we value diversity and recognize it to be a core part of our success. Because of the diversity of our employees, affiliated health professionals and volunteers, we are... positioned to meet the unique needs of our patients and community. We acknowledge and celebrate the uniqueness and talent of each employee. Because of our talented workforce we are able to provide a quality healthcare experience to our patients and community. We strive to create an inclusive environment in which individual diversity can be leveraged and thrive. Christiana Care Health System is an equal opportunity employer, firmly committed to prohibiting discrimination, whose staff is reflective of its community and considers qualified applicants for open positions without regard to race, color, sex, religion, national origin, sexual orientation, genetic information, gender identity or expression, age, veteran status, disability, pregnancy, citizenship status, or any other characteristic protected under applicable federal, state, or local law.