PRIMARY FUNCTION: 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 health care team to formulate a discharge plan that provides the patient services in the appropriate post-acute care setting. Gathers and assesses information regarding the patient's physical needs, mental status, family support system, financial resources, and available community and governmental resources. Employs assessment 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 utilization management to manage length of stay. Maintains contact with the patient's third party payors to ensure the most cost-effective plan of care is being carried out and appropriate in network 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 discharge plan through service referral and coordination activities. The Social Worker always assures that the patient is given the choice in regard to agencies and services. As part of the discharge plan development process, collaborates with other healthcare professionals in multi-disciplinary meetings and patient rounds. Screens high-risk patients and consults attending physicians regarding potential discharge 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 factual information based on current knowledge, to provide psychosocial support and assist the patient/family in coping with their disease to improve their overall health care management. Provides specific information on how to communicate with physicians and other hospital staff to better utilize the hospital resources and increase understanding of the disease process. In accordance with established clinical guidelines, standards, and pathways, establishes a comprehensive discharge plan for those patients with post-acute care needs. The Social Worker will organize, secure, integrate and modify the resource necessary to meet the goals stated in the discharge plan. The Social Worker will monitor patient care across the continuum through follow-up with patients, families, and community services. Educates the community and the general public regarding various symptoms and consequences related to specific diseases, conditions and hospitalization. This information will also include specifics regarding methods of professional intervention and description of the process of social work intervention in a medical setting. Represents patient/family by intervening, negotiating and promoting their concerns. Problems requiring advocacy may include individual and class inequities or inadequate and non-existent hospital and/or community resources, i.e., insurance benefits, housing, etc. Functions as consultant/advisor to hospital administration, utilization review, public and private insurance programs when discharge planning or utilization "impasse" situations occur. Keeps administration informed of changes in community, state, and federal policies that impact on the length of stay. Maintains pertinent and timely documentation in patient's medical charts and departmental records. Accurately maintains required departmental statistical data. Collects and maintains specific information required for performance improvement indicators and research projects. Utilizes the department Quality Service Plan to address service issues as needed. Performs patient/family evaluations and histories. Provides psychosocial support through individual, group, or family counseling, as needs dictate. Continuously reviews service area for group support needs and opportunities. Represents Christiana Care, when requested, through participation on community/state boards, committees, panels, court hearings, etc. Attends regularly scheduled staff meetings, i.e., team, divisional, or center-wide. Participates in a minimum of one committee within the Department of Social Work after having at least one year of service. Supports the departmental educational and staff development initiatives including supervision of undergraduate/ graduate 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 in-service presentations regarding new resources and clinical techniques. Provides voluntary, confidential, short-term, therapeutic intervention and referral service for employees, attending staff, and their families. 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.

SCOPE, PURPOSE, AND FREQUENCY OF CONTACTS: Consistent daily contact with patients, families, medical and other professional staff from various hospital departments, community agency representatives, governmental officials, and politicians.

DIRECTION/SUPERVISION OF OTHERS: May supervise one or a maximum of two (2) graduate or undergraduate students at a given time. Provides direction to members of assigned team in the absence of Team Leader, Supervisor or Social Work Director.

DIRECTION/SUPERVISION RECEIVED: Team Leader for worker's assigned area, Supervisor or Social Work Director. Attends team meetings to review case concerns and supervisory sessions called at the discretion of the Social Work Administration Team.

EDUCATION AND EXPERIENCE REQUIREMENTS: Masters degree in Social Work from an accredited graduate school of Social Work. Two years of social work experience in a medical setting. Training time on the job is six months to one year.

KNOWLEDGE, SKILL, AND ABILITY REQUIREMENTS: Knowledge of Social Work Theory and understanding and acceptance of Social Work Code of Ethics. Knowledge and use of Christiana Care core values: caring, excellence, integrity, leadership, pride, teamwork. Knowledge of Crises Intervention Theory. Knowledge of Human Behavior and Developmental/Life Cycle Theory. Knowledge of community resources, state and federal programs. Knowledge of individual group and family therapy. Ability to relate to people like and different from self. Ability to function as a member of an interdisciplinary team. Ability to learn and understand medical terminology. Ability to organize and prioritize (sometimes very heavy) work assignments. Ability to consistently present clear professional identity and purpose. Ability to work with minimal supervision, if necessary. Ability to maintain flexibility and emotional stability while working under intense emotional, time and volume pressure.

SPECIAL REQUIREMENTS: Licensed Clinical Social Worker (LCSW) preferred but not required.

EEO Statement: 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.

UPDATE: ChristianaCare is committed to prioritizing the health and safety of our patients and caregivers. As we continue to meet the needs of our caregivers and our community through the COVID-19 pandemic, our commitment to health and safety requires that we take new steps to ensure a safe environment for medical care for our patients and a workplace that avoids preventable harm for our caregivers. For this reason, vaccination for COVID-19 is required for all caregivers at ChristianaCare and is considered a safety standard that is job-related and consistent with business necessity for all caregivers.