The Social Worker is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patientï¿½s resources and right to self-determination.The individual in this position has overall responsibility for to assess the patient for transition needs including identifying and assessing patients at risk for readmission.Conducts complex psycho-social assessment and intervention to promote timely throughput, safe discharge and prevent avoidable readmissions.This position integrates national standards for case management scope of services including:
Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care
Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
Education provided to physicians, patients, families and caregivers
This individualï¿½s responsibility will include the following activities: a) complex psycho-social transition planning assessment and reassessment and intervention, b) assistance with adoptions, abuse and neglect cases, including assessment, intervention and referral as appropriate to local, state and /or federal agencies, c) care coordination,d) implementation or oversight of implementation of the transition plan, e) leading and/or facilitating multi-disciplinary patient care conferences including Complex Case Review, f) making appropriate referrals to other departments, g ) communicating with patients and families about the plan of care, h) collaborating with physicians, office staff and ancillary departments,i) assuring patient education is completed to support post-acute needs , j) timely complete and concise documentation in Case Management system, k ) maintenance of accurate patient demographic and insurance information, l) and other duties as assigned.
POSITION SPECIFIC RESPONSIBILITIES:
ï¿½Completes comprehensive assessment within 24 hours of patient admission to identify and document the anticipated transition plan for patients
ï¿½Integrates key elements of patient assessment, patient choice and available resources to develop and implement a successful transition plan
ï¿½Completes Complex/Psycho-social assessment and plan for patients identified as high risk for readmission.
ï¿½Provides psycho-social assessment and intervention for patients identified with identified needs including behavioral health, lack of support systems, financial barriers, end of life, and/or medication adherence.
ï¿½May delegate the implementation of the transition plan to LVN/LPN or Assistant staff. And follows up to ensure the transition plan is completed timely and accurately
ï¿½Ensures all elements of the transition plan are implemented and communicated to the healthcare team, patient/family and post-acute providers
ï¿½Provides information to patients to make informed choices when community services per Tenet policy
ï¿½Completes Final Discharge Disposition Form Assessment for Medicare patients per Tenet policy
ï¿½Completes timely, complete and accurate documentation in the Tenet Case Management system to communicating information to the care team and provide documents needed in the patient record
(40% daily, essential)
ï¿½Screens patients for factors that may affect the progression of care and intervenes as needed to promote timely and appropriate throughput
ï¿½Conducts assessments and stratifies patients at risk for readmission or in need of Case Management services
ï¿½Assists with adoption/abuse/neglect cases and reporting of appropriate cases to local, state and/or federal agencies
ï¿½Ensures the plan of care is consistent with patient choice and available resources
ï¿½Ensures patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of care
ï¿½Effectively collaborates with physicians, nurses, ancillary staff, payors, patients and families to achieve optimal outcomes
(40% daily, essential).
ï¿½Ensures and provides education to patients, physicians and the healthcare team relevant to the safe and timely patient transition
ï¿½Provides patient and healthcare team education regarding resources and benefits available to the patient along with the economic impact of care options
ï¿½Ensures that education has been provided to the patient/family/caregiver by the healthcare team prior to discharge (10% daily, essential).
ï¿½Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services
ï¿½Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and Tenet policies
ï¿½Operates within the Social Work scope of practice as defined by state licensing regulations (10% daily, essential)
1.Master's degree in Social Work from a college or university social work program approved by the Michigan Board of Social Work and accredited by the Council on Social Work Education.
2.Current license as a Licensed Master's Social Worker in the State of Michigan, or current limited license to engage in the practice of social work at the Master's level in the State of Michigan, with full licensure within 3 years from date of hire .
3.Two years of acute hospital experience preferred.
4.Must complete and demonstrate competency in using the Tenet Case Management documentation system within 30 days of hire.
5.Attendance at hospital and department orientation is required.Department orientation includes review and instruction regarding Tenet Case Management and Compliance policies, Transition Management, and other topics specific to case management.
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Internal Number: 1905010242
About DMC Harper University/Hutzel Women's Hospital
“Tenet Healthcare Corporation is a diversified healthcare services company with 115,000 employees united around a common mission: to help people live happier, healthier lives. Through its subsidiaries, partnerships and joint ventures, including United Surgical Partners International, the Company operates general acute care and specialty hospitals, ambulatory surgery centers, urgent care centers and other outpatient facilities. Tenet's Conifer Health Solutions subsidiary provides technology-enabled performance improvement and health management solutions to hospitals, health systems, integrated delivery networks, physician groups, self-insured organizations and health plans.