- In support of patient progression practice, create optimal outcomes for the patient and the family by managing complex psychosocial and economic barriers to patient progression.
- Through advanced practice skills mobilizes resources to reduce risk to the patient and families secondary to social determinant-based needs and challenges.
- Provides patient support with cultural humility to ensure that interventions by the care team are rendered respectfully to diverse populations.
- Identifies patient and/or families requiring coordination of continuing care or community support members of the care team.
- Reviews medical records, attends rounds, and responds to patient’s needs.
- Applies knowledge based on professional experience.
- Understands and adheres to the practice standards consistent with patient progression and its contribution to the strategic plan.
- Works collaboratively with the RN Case Manager and the treatment team members to develop and coordinate a safe, timely and appropriate discharge plan across the care continuum, addressing psychosocial barriers, with multiple resource dependent level of care options that comply with regulations and laws regarding patient/family participation with planning and choice.
- Coordinates post-acute discharges for complex patients in collaboration with Care Management Discharge Manager.
- Identifies the need for and conducts in a timely fashion patient family meetings that result in decisions regarding advance directives, comfort measures, power of attorney, guardianship, conservatorship, and goals of care.
- Completes initial psychosocial screen of patients and families as indicated.
- Serves as the lead in addressing psychosocial needs of patients relating to social determinants of health, barriers to equal access to healthcare, and patient progression; this includes obtaining charity and financial resources, legal guardianship, adoptions, psychiatric referrals, and competency determination.
- Provides referrals for post-acute transitions to/for LTACH, SNF, IRF, LTC , HH and DME.
- Conducts practice consistent with social work ethical principles, adhering to standards set forth from NASW and ACMA Case Management practice standards.
- Identifies the need for and conducts family meetings that result in comfort, treatment and discharge planning decisions, and other important outcomes.
- Leads Care Coordination/Interdisciplinary Rounds and documents.
- Advocates for patient care and timely discharge plan.
- Works with people and agencies in the community to improve responsiveness, capabilities, alignment, and evaluation of services to patients and families.
- Utilizes age-appropriate assessments and interventions during all client contacts.
- Collaborate with Risk Management, Patient Relations, Utilization Management, the Ethics Committee and other departments for ethical issues and utilizes the NASW Code of Ethics in appropriate decision-making.
- Demonstrates flexibility and partnership with the care management team members to ensure the needs of patients are met.
- Assists patients and families in understanding their illness and treatments options, consequences to various treatments or refusal of treatment, and necessary levels of care, including acute, subacute, and community services.
- Assists patients and families in communicating with treatment team Educates hospital staff on patient psychosocial needs.
- In addition to the above job responsibilities, other duties may be assigned.
- Minimum requirements
Education
Master's of Social Work required.
Experience
One year of experience performing discharge planning in an acute or subacute setting.
Licensure
LMSW/LCSW preferred. ACMA certification preferred.
- PHYSICAL DEMANDS Job requires standing for prolonged periods, frequently walking, bending/stooping.
- Proficient communicative, auditory and visual skills; Attention to detail and ability to write legibly; Ability to lift/push/pull 20-50 lbs.
- May be exposed to chemicals, blood/body fluids, and infectious disease.
- The starting base rate for this role is $66.00 hourly.
- Individual compensation will be determined by the selected candidate's qualifications, previous work experience, and/or education.
- UVA Health is a world-class Magnet Recognized academic medical center and health system with a level 1 trauma center.
- 2023-2024 U.S.
- News & World Report “Best Hospitals” guide rates UVA Health University Medical Center as “High Performing” in 5 adult specialties and 14 conditions/procedures.
- We are one of 70 National Cancer Institute designated cancer centers.
- UVA Health Children’s is named by 2023-2024 U.S.
- News & World Report as the best children's hospital in Virginia with 9 specialties ranked among the best in the nation.
- Our footprint also encompasses 3 community hospitals and an integrated network of primary and specialty care clinics throughout Charlottesville, Culpeper, Northern Virginia, and beyond.
- The University of Virginia is an equal opportunity employer.
- All interested persons are encouraged to apply, including veterans and individuals with disabilities.
- Learn more about UVA’s commitment to non-discrimination and equal opportunity employment.
