Department: Care Management Services FTE: 1.00 Full Time Shift: Days
Position Summary: Manage the medically related social and emotional needs of patients and their families as needs impinge on patient medical conditions, treatment, recovery and safe transition from one level of care to another. Coordinate care with physicians, nursing staff, case managers and allied health professionals ensuring that patient outcomes are achieved within established timeframes and with maximum efficiency in resource utilization. Conduct high-risk screening, initial and ongoing psychosocial assessments. Ensure continuity of care through case management and discharge planning, providing social work interventions to expedite timely discharges, monitoring patient outcomes, and analyzing variances. Ensure adherence to Hospitals and departmental policies and procedures. Patient care assignment may include Neonate, Pediatric, Adolescent, Adult and Geriatric age groups.
Detailed responsibilities: * PATIENT CENTERED MED - Adhere to and promote the core expectations of the Patient Centered Medical Home or Patient Centered Specialty Practice as applicable * IDENTIFICATION - Identify appropriate patients within designated specialty area requiring patient case management interventions by utilizing established procedures including census review, risk screens, and referral * CASE MANAGEMENT - Provide case management and discharge planning services in a timely and cost-effective manner to include patient assessment, planning, implementation, coordination, monitoring and evaluation * ASSESSMENT - Complete psychosocial assessment of identified patients whose medical status, recovery, or timely discharge may be impeded by inadequate social, environmental, or economic conditions, by inadequate funding sources, and/or by impaired emotional or cognitive status including decisional incapacity * ASSESSMENT - Assess patient level of functioning, including developmental, physical, environmental, cognitive, behavioral, psychological, economic, social, cultural and spiritual factors * PATIENT ASSISTANCE - Provide assistance to facilitate patient recovery, discharge and/or management of an acute, chronic or terminal illness or condition; assistance may include education, community referrals, advocacy, and mediation with patients and families to assist in adjustment to changes in health status and functioning expediting timely discharge to an appropriate level of care * OUTCOMES - Identify patients with a history of medical non-compliance, high resource utilization and poor outcomes; monitor patient outcomes, re-evaluate plans of care to accommodate changes in treatment or progress * GOALS & OBJECTIVES - Assist in resolution of identified barriers and develop alternative goals and objectives with patients and family members * DOCUMENTATION - Document assessment data, patient problems, interventions taken to achieve outcomes and evaluation of patient progress toward targeted outcomes * LIAISON - Serve as UNMHSC liaison to state protection agencies for all reports and/or concerns of patient abuse, neglect or exploitation * LEGAL COORDINATION - Coordinate with UNMHSC Office of Legal Counsel regarding matters involving treatment guardianship and/or other legal issues * COMMUNICATION - Use effective communication strategies with patients, families, physicians, nurses, allied professionals and others to achieve desired patient outcomes and patient satisfaction * CARE COORDINATION - Coordinate multidisciplinary care planning, including patient care conferences as appropriate to facilitate resolution of treatment decisions and timely discharge planning * RELATIONS - Develop and maintain positive relationships with community agencies and third party payor sources * EDUCATION - Contribute to education of physicians, nurses, allied health professionals and students * RESOURCE - Acts as resource to professional colleagues; provide staff training, development and consultation as appropriate * DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops * PATIENT SAFETY 1 - Follow patient safety-related policies, procedures and protocols * PATIENT SAFETY 2 - Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processes * PATIENT SAFETY 3 - Identify and report/correct environmental conditions and/or situations that may put a patient at undue risk * PATIENT SAFETY 4 - Report potential or actual patient safety concerns, medical errors and/or near misses in a timely manner * PATIENT SAFETY 5 - Encourage patients to actively participate in their own care by asking questions and reporting treatment or situations that they don't understand or may "not seem right" * LIVING DONOR ADVOCATE - Assist the living donor in obtaining and understanding information regarding the following: evaluation and consent process, surgical procedure, risk and benefit of donation, financial aspects of living donation, options available to the recipient other than live donor kidney transplantation, short and long term consequences of kidney donation and the need for long term follow up post donation * LIVING DONOR ADVOCATE - Promote, protect, represent, and advocate for the rights of potential living kidney donors throughout all phases of the transplant process * LIVING DONOR ADVOCATE - Respect donor's decision and ensure that decision is voluntary, informed and free of coercion * LIVING DONOR ADVOCATE - Maintain confidentiality and ensure donor has an understanding of the "Opt-Out" process
Experience: Essential: No minimum experience required
Nonessential: Bilingual English/Keres, Tewa, Tiwa, Towa, Zuni, or Navajo
Credentials: Essential: * NM LMSW or LPC or LCSW * CPR for Healthcare/BLS Prov or Prof Rescuers w/in 30 days Nonessential: * Licensed Clinical Social Worker in New Mexico * Licensed Master's Social Worker in New Mexico
Physical Conditions: Sedentary Work: Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
Working conditions: Essential: * No or min hazard, physical risk, office environment * May be required to travel to various work sites * May be required or is required to perform on-call duties * May work rotating shifts, holidays and weekends