Care Management Social Worker I
Alameda Health System
- Oakland, CA
- Training
- Full-time
- Collaborates with Care Transition team and Health Advocates for high risk patients for timely follow-up appointments and confirms prior to discharge that complex patients are appropriately linked to community services.
- Coordinates patient care activities with other members of the healthcare team, the patient, the patient's representatives, and community partners and makes referrals as appropriate.
- Effectively intervenes in suspected abuse/neglect cases and in complex or high risk situations as requested; is competent to identify and intervene with high risk behaviors, responding to traumas.
- Identifies and mobilizes patients and family strengths to optimize use of healthcare and community resources; in coordination with patient and family wishes, guide/assist in securing needed post discharge services which may require negotiating for services covered but not readily available; provides consultation and education to team members regarding patient/family (psychosocial and discharge planning) issues and community resources.
- Identifies potential problems prevents and or resolves variances to the care management plan; assesses and coordinates family and community resources to meet identified needs to support the discharge plan.
- Intervene with patients and patient's representatives regarding emotional, behavioral, and financial barriers to current illness and/or disability.
- Leads patient centered conferences to meet needs and desires of the patients.
- Maintains patient records including patient assessments, plans interventions, patient/family involvement, outside agency communications and interdisciplinary contacts.
- Participates in discharge planning activities; effectively identifies and intervenes with high risk discharge planning issues with psychosocial complexity; whether referred by other healthcare providers or identified through assessment. Assists Care Management Nurse with discharge planning efforts as requested; obtains or coordinates referrals for post-discharge service needs, if required; mobilize resources to affect rapid and timely movement of the patient through system to achieve targeted discharge times established by AHS.
- Performs psychosocial assessment interview with patients and/or families and records this assessment in the patient's medical record. Assesses patient's level of functioning, environment, appropriateness and adequacy of support system related to illness and ability to cope; reassesses the patient's condition when changes occur and revises the care plan when appropriate. Performs rapid assessments and developing crisis management plans for referral, evaluation and admission.
- Provides patient advocacy including primary responsibility for initiating processes regarding capacity determinations, grief counseling, and conservatorship/guardianship; takes advocacy leadership role regarding adoption/surrogacy cases.
- Refers and assists patients/families in applying for appropriate financial programs (CCS, SDI, SSI, SSD, private pensions) and legal instruments as needed.
- Screen for any barriers to care such as substance abuse, neglect, financial limitations or housing.
- Serves a resource and provides counseling and treatment related to palliative care or end of life planning.Provides crisis intervention, bedside counseling and resources/referrals for mental health care.