Social Worker II-MSW - Main Social Work - LVAD - Full Time - Days

Job Description

PRIMARY PURPOSE: To provide services to The Christ Hospital patients and families by assessing psychosocial needs and implementing a discharge plan of care to assure continuity of the patient's care. Provides psychosocial interventions, advocacy and linkage with community resources. Specific focus area is with LVAD Inpatients.

Responsibilities

ASSESSMENT/SCREENING

• Assess patients' evolving medical situation from a psychosocial framework, including functional status, goals of care, and community support needs as it relates to discharge planning
• Assess family structure, dynamics, and decision-making preferences, including identification of a surrogate decision maker if needed
• Assess patient/family environmental risk factors, patient/family/community support systems, age-related/developmental issues, financial barriers, health literacy, chemical dependency/mental health, Social Determinants of Health needs, and any risk of abuse/neglect/financial exploitation/intimate partner violence
• Assess for risk of readmission, putting into place a coordinated plan for outpatient follow up

Documentation:

• Documents in Discharge Planning progress notes a clear, concise, objective psychosocial assessment, treatment plan, and progress of social work intervention and outcomes in compliance with regulatory standards and department standards for timeliness.
• Documents appropriately in the Social Work module for data tracking purposes

DISCHARGE PLAN IMPLEMENTATION/CARE COORDINATION

Develop a plan of intervention, which is integrated with the interdisciplinary treatment team to establish continuum of care in congruence with ethical and legal considerations.

Implements plan of care:

• Provide psychosocial counseling and other therapeutic interventions for patient/family
• Provide crisis management for patient/family
• Facilitate healthcare decision making and resolution of discharge planning issues
• Provide psychosocial intervention for: neglect/abuse/intimate partner violence/human trafficking; adjustment to illness; bereavement and mental health; substance abuse; non-compliance, and other psychosocial barriers to diagnosis and treatment
• Mandated reporting to local/state agencies as required by law - Adult Protective/Child Protective Services, law enforcement
• Maximize health status and minimize length of stay and appropriate utilization of hospital resources
• Provide referral and linkage to health care and community resources based upon Social Determinants of Health screening needs
• Facilitate extended care facility placement and hospital to hospital transfer
• Facilitate home care, hospice care, and durable medical equipment arrangements
• Advocate, mediate and negotiate a cohesive plan for maintaining or improving social supports and patient safety
• Coordinate patient's discharge plan with outpatient counterparts - TCHMA SW, insurance case managers, community mental health/substance abuse case managers - to aid in readmission prevention

CONSULTATION/EDUCATION/COLLABORATION

• Attend unit specific Inter-Disciplinary Rounds daily
• Collaborate with interdisciplinary team to enhance quality of care and efficiency.
• Maintain a positive working relationship with healthcare team and community agencies and services.
• Provide extensive education to patient/family in areas of insurance benefits, and capacity of community resources to meet patient needs
• Participate in interdisciplinary patient care rounds, case conferences and family conferences for purpose of appropriate length of stay discharge planning.
• Assist interdisciplinary team in understanding significant social and emotional factors related to illness.
• Identify barriers in service delivery systems and advocate for change.
• Provide education to interdisciplinary team, residents, students, other disciplines and community agencies
• Evaluate patient outcomes and participate in process improvement.

CONTRIBUTIONS TO THE SOCIAL WORK DEPARTMENT

• Provide leadership and perform delegated management responsibilities.
• Provide clinical supervision to peers, Bachelor degree staff, and students.
• Provide mandatory and/or voluntary cross coverage when needed.
• Participate in orientation of new staff.
• Generate and support ideas to improve Social Work Department service delivery systems.
• Identify complex clinical cases and seek supervision when appropriate

LVAD SPECIFIC DUTIES

• Ensures protection of the right of VAD Recipients and promotes their interests.
• Develop a plan of intervention with Advanced Heart Failure patients / pre-VAD and VAD inpatients, which is integrated with the interdisciplinary treatment team to establish continuum of care in accord with ethical and legal considerations.
  • Includes following tasks:
  • Completion of Advanced Heart Failure Therapy Assessment / LVAD Assessment on Inpatients (see next page)
  • Collaborate with VAD RN staff to process specialty medication prior authorizations and appeals with insurance companies
  • Secure reimbursement for medication patient assistance applications as needed
  • Acute Rehab, LTAC, SNF, Hospice, Home Health, Wound Vac, Unskilled Community Support, Infusion and Dialysis referrals/planning
  • Secure high cost ambulance/air care arrangements for hospital to hospital transfers, and determine use of hospital resources to assist with transportation as needed.
  • DME/Driveline dressing supplies/Oxygen referrals and ongoing management, negotiation with insurance on approvals/appeals if needed.
  • VAD Clinic follow up coordination with Clinic and patient/family.
• Provide clear, concise, timely objective written communication of the psychosocial assessment, treatment plan, progress of social work intervention and outcomes in compliance with regulatory and department standards
• Administer depression screening/safety evaluations as needed for patients as identified by Inter-Disciplinary team
• Assist in providing staff sessions and debriefings after difficult cases as often as needed in collaboration with Palliative Care Team NPs and Chaplains.

FULL PSYCHOSOCIAL EVALUATION FOR:

1. LVAD SURGICAL CANDIDACY AT TCH

2. ADVANCED HEART FAILUE ASSESSMENT - For patients who may not necessarily be medically appropriate for LVAD at this time but have been identified by HF MD as needing advanced heart failure therapy such as but not limited to LVAD, RVAD, heart transplant, outpatient Palliative Care or hospice once medical course/therapy recommendations are determined. This includes patients who previously may not have been managed by the LVAD IDT.

TASKS FOR BOTH ASSESSMENTS:

• Review insurance coverage with Financial Counselor to determine if patient could benefit from secondary insurance to cover out of pocket costs/SSDI application.
• Work with team based on patient's insurance and biopsychosocial needs to determine best center to refer for services not offered at TCH such as heart transplant, dual organ transplant, RVAD, etc.
• Make highly critical decisions and recommendations related to life sustaining advanced heart failure therapies based on psychosocial assessment (BSW staff person consult with MSW VAD counterpart or SW Team Lead particularly on Mental Health, Addiction History and Patient/Caregiver Motivation):
  • Social history and support system
  • Understanding of potential medical course and answering questions regarding options of: LVAD, RVAD, heart/dual organ transplant, home inotropic medications, or palliative/hospice care.
  • Together with Speech/Language Pathologist, assessing if patient has mental capacity to make healthcare decisions and is capable of self-management with medical treatment - this may vary due to low cardiac output or complications of medical course as well as learning disabilities.
  • Lifestyle factors: smoking, drug use, alcohol use, non-adherence to medical recommendations, collaboration with community providers.
  • Mental and Psychiatric status (past and current), coordination of care for mental health while inpatient and continuation in outpatient setting
  • Addiction history and management of adherence to ongoing treatment and compliance with treatment plan
  • Financial/Insurance/Work history
  • Assess caregivers to determine no physical, mental or environmental factors would prevent them from providing comprehensive care to patients and that a backup caregiver has been identified should the primary be unable to fulfill their duties.
  • Completion of SIPAT screening tool for each referral.
  • Patient and caregiver motivation for successful post-op course - make judgements/decisions regarding internal conscious and unconscious defense mechanisms
• Provide clinical input to weekly VAD Selection Committee meetings, monthly QAPI and PECOC meetings
• Arrange and provide input at Inter-Disciplinary Team (IDT) and family meetings
• Together with Outpatient VAD Social Worker, develop and present annual TCH Social Work in-service for VAD competency
• Maintain competency on LVAD and Advanced Heart Failure Therapy options (i.e. changes in LVAD models, transplant process, absolute contraindication, etc.)
• Maintain Advanced Heart Failure and LVAD Program Social Work guidelines and support to all staff as well as input to program changes, policies and procedures
• Provide cross-coverage to VAD outpatient needs when co-worker is on PTO/leave
• Provide support to Social Work med/surge team for weekend/holiday coverage and other emergent needs throughout Social Work Department

Qualifications

KNOWLEDGE AND SKILLS:

Exceptional skill interviewing patients and families in crisis and individuals with a wide range of physical and emotional problems. Ability to prioritize many simultaneous demands. Medical and psychiatric competence including knowledge of health policy, regulations, and legislation and community resources. Self-awareness, professionalism, and good judgment in dealing with emotional and confidential issues. Excellent verbal and written communication. Skill in social work assessment and treatment modalities necessary to assess and treat individuals, families and groups. Ability to integrate social work philosophy and ethics into professional practice.

EDUCATION:

Master's degree in social work (MSW) required.

LSW/LISW required.

YEARS OF EXPERIENCE: 2 years clinical experience in hospital, long-term care or hospice setting preferred.

LICENSES & CERTIFICATIONS:

Assure ongoing licensure through the State of Ohio Counselor, Social Worker, and Marriage and Family Therapist Board