Las Palmas Medical Center is a Level III Trauma, 186-private patient room, full service acute care hospital. Las Palmas Medical Center offers comprehensive healthcare and provides leading-edge technologies. Our Lifecare Center offers inpatient and outpatient rehabilitation programs, as well as our fully equipped fitness and wellness center in one convenient location. We also house the region's only Kidney Transplant Center.
We are located on the Westside of El Paso, Texas close to the University of Texas El Paso campus. We provide exceptional patient care services to the El Paso and Fort Bliss communities, as well as Southern New Mexico and West Texas Regions.
The Social Worker will evaluate the psychosocial needs of patients and family support systems and will coordinate appropriate discharge plans for patients on the rehab unit. The Social Worker acts as a liaison between the facility and resources external to the organization. He/she will facilitate implementing timely discharge plans and facilitate follow-up to anticipated post-acute interventions identified in the plan of care. The Social Worker will provide crisis intervention and support. The Social Worker will assist the Rehab Team in facilitating patient movement across the continuum of care and will identify and track barriers to patient throughput.
All patients admitted to the hospital, emergency room, or outpatient areas and their families and/or caregivers. ESSENTIAL FUNCTIONS:
Qualifications: REQUIRED LICENSURE/CERTIFICATIONS:
- Performs a comprehensive assessment of psychosocial needs of assigned patients; Involves patient, family/responsible/significant others, develops, implements, monitors and revises plan of care in collaboration with the interdisciplinary team
- Assesses patients discharge needs and facilitates the provision of services necessary to meet identified needs;performs home health referrals, intermediate care and skilled nursing facility referrals, assist patients with medication acquisition, facilitates follow up appointments, arranges public transportation, etc.
- Evaluates suspected abuse and neglect referrals; makes official reports to state and regulatory or legal agencies as required by statue or facility policy
- Develops an individual plan of care for recurring patients to include education related to accessing healthcare services at the appropriate level of care; preventative education, and community based resources, provides assistance with access to medication assistance programs
- Provides education to the under-resourced patient/family of potential and available resources; identifies needs, coordinates the development of realistic plans which include patient/family centered goals, facilitates implementing plan, and performs follow-up evaluation
- In collaboration with the interdisciplinary team, develops, implements, evaluates, revises as needed, a discharge plan to include identified psychosocial and discharge needs
- Documents professional recommendations, care coordination interventions and case management activities to effectively communicate to all members of the health care team
- Participates with the interdisciplinary team to ensure psychosocial and discharge needs are addressed; plan, interventions and patient/family/MD concurrence will be documented
- Acts as a liaison through effective and professional communications between and with physicians, patient / family, hospital staff, and outside agencies
- Demonstrates knowledge of regulatory requirements, HCA Ethics and Compliance policies, and quality initiatives; monitors self-compliance and implements process changes to ensure compliance to such regulations and quality initiatives as it relates to the provision of Case Management Services
- Makes appropriate referrals, after collaboration with the Case Manager, to third party payer disease and case management programs for recurring patients and patients with chronic disease states
- Facilitates patient throughput with an ongoing focus on quality outcomes and an efficient transition between levels of care
- Tracks and trends barriers to care; makes recommendations and develops action plans to improve processes and systems
- Provides psychosocial support to patients and families through crises intervention
- Actively seeks ways to control costs without compromising patient safety, quality of care or the services delivered
- Acts as an advocate for identified needs and makes appropriate referrals; abuse and neglect, substance abuse/overdose, homelessness, post-partum patients < 17 years of age, fetal demise, mother-baby bonding, adoptions, guardianship, etc.
- Acts as a liaison between the facility and community resources to enhance community outreach
- coordination; establishes and maintains resource database, educates peers and patients on resources, performs community outreach as directed
- Tracks and trends variances barriers related to access to care; makes recommendations and develops action plans to improve processes and systems
- Adheres to established policy and procedure and standard of care; escalates issues through the Chain of Command
Bachelor of Social Work LBSW, Master of Social Work with current state licensure; CMSW, DCSW or LCP preferred. REQUIRED EDUCATION/EXPERIENCE:
3 years Social Work experience; acute care social work or case management experience preferred. PREFERRED EDUCATION, LICENSURE, CERTIFICATION, EXPERIENCE, SKILLS, KNOWLEDGE AND ABILITIES:
Certification in Social Work or Case Management, preferred. Ability to establish and maintain collaborative and effective working relationships. Ability to communicate effectively in oral, written and electronic formats. Demonstrates analytical and critical thinking abilities with pro-active decision making and negotiation skills. Demonstrates an ability to perform specific competencies as identified.