Enthusiastic Social Worker with medical social work background. Works effectively with patients and families experiencing medical crises by acting as advocate and guide throughout difficult and emotionally-draining situations.
Performs duties relevant to addressing the psychosocial concerns of Memorial Health System patients and families. Mobilize health, psychosocial, and economic resources in order to promote optimal outcomes for the patient and family. Collaborates and partners with patients and providers as an integral member of the care team and act as a liaison by advocating between the patient, family, healthcare providers, services, and community agencies in order to expedite use of healthcare services in the community and across the continuum of care.
Utilizing specialized knowledge and experience, make assessment of patients' psychosocial needs, home situation and economic constraints
Serve as liaison between patients/ families and community agencies
Coordinate information and referrals for financial and community resources to link patients/families to the appropriate resources.
Serve as resource to clinical team, patients and families regarding entitlement to programs and support services
Develop strong working relationships with internal and external healthcare organizations and community resources.
Work with patients to formulate an individualized plan to obtain medication, particularly, in light of Medicare coverage limitations including the facilitation of enrollment in various drug companies' patient assistance programs when warranted
Work closely and collaboratively with the clinical care team across sites of care
Assist the team with care delivery by scheduling appointments, arranging interpreters, assisting with the completion of forms, ensuring that patients can access services, and arranging transportation to and from medical appointments as needed
Participate in clinic office visits, team rounds, or family conferences with when needed based on site of care
Coordinate patient care with other disciplines involved in the plan of care and maintain appropriate documentation
Confer with the patient, family, and clinical team to obtain information to coordinate efficient and quality patient care.
Build relationships with primary care providers, skilled nursing facilities, and the community to promote continuity of care
Provide crisis intervention and supportive counseling for patients and their families as needed
Serve as patient advocate, assisting with navigation of patient eligible resources and programs
Provide patients and families with support and information to overcome personal and environmental difficulties which pre-dispose toward illness or interfere with obtaining maximum benefits from medical care
Assist patients to effectively utilize available resources to meet their personal health needs and help them develop their own capabilities
Evaluate patients' ability to independently manage self and locate alternative resources when limitations are identified
Maintains a working knowledge of relevant medical/legal issues that impact patient care, e.g., advance directives, power of attorney, and guardianship.
When requested, provide group, individual, and family counseling to patients and their families as requested
Initiate discharge planning when patient is admitted.
Assure that discharge plans are secured when patient is medically ready for discharge
Assure that all necessary information has been transmitted to next provider of care.
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