SocialWorker-PRN-DCMC

Position Objective: Provides counseling, crisis intervention, and transition planning services to AAMC patients of all ages and their families. Performs psychosocial assessments, plans for and implements identified services for patients. Essential Job Duties: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions In accordance with established department and professional guidelines, provides comprehensive psychosocial assessments for patients identified by Care Coordinator, and/or interdisciplinary team. In counseling role, creates a therapeutic framework for effective problem solving with patient and family. Responds to patient/family needs related to adjustment to illness, disability, critical care issues, acceptance of discharge recommendations, need for long-term care placement, end of life, grief, trauma, abuse and neglect, substance abuse, and mental health issues. In collaboration with Care Coordinator, provides transition of care strategies in complex situations such as: substance abuse, psychiatric, or dual diagnosis placement/services, ventilator dependent patients, inpatient dialysis services, patients with no insurance needing skilled nursing facility placement, patients requiring guardianship, long term/custodial placement. Identifies community services and resources available to patients and families and facilitates linkage with those services. Collaborates with the interdisciplinary team and communicates to him/her the progress and status of referred patients. Makes recommendations and revises plan based on continued evaluation and collaboration. Communicates proactively with members of care management and the interdisciplinary team as appropriate and indicated. Evaluates patient/family progress toward established goals. Participates in Care Conferences and Complex Care rounds as indicated to address patient/family issues/barriers and to help facilitate safe transitions of care. Integrates medi