Case Management/Social Work Job: Social Worker II at Houston Methodist in Houston Methodist Sugar Land Hospital (2024)

PEOPLE ESSENTIAL FUNCTIONS

• Role models communication in an active, positive and effective manner to all health care team members and reports pertinent patient care and family data in a comprehensive and unbiased manner, listens and responds to the ideas of others. Uses therapeutic communication to establish a relationship with patients and families and communicates the discharge plan, facilitating transitions and hand-offs. Supports patients and families in clinical or ethical issues.

• Provides staff education specific to patient populations and departmental processes. Functions as a preceptor and mentor to new employees. Identifies opportunities for professional growth of self and peers.

SERVICE ESSENTIAL FUNCTIONS

• Serves as a hospital/post acute-based leader for comprehensive case management activities including assessing high-risk patients and leading team to identify at-risk patients, participating in daily Care Coordination rounds, and identifying and leading resolution to barriers of efficient patient throughput. Completes a full assessment based on the social work assessment, leading and addressing solutions of social determinants which is accomplished by patient/family interview, review of the medical record including previous episodes of care, H&P, lab and other test results/findings, plan of care, physician orders, nursing and progress notes. Uses advanced knowledge and clinical expertise and screening tools to identify need for case management and/or social work intervention.

• Addresses and manages conflict associated with a comprehensive psychosocial treatment plan utilizing appropriate clinical social work diagnoses, treatments and interventions, including crisis intervention, brief individual, marital and family therapies, and patient, family and caregiver groups. Maintains ownership of the psychosocial component, assessments, diagnosis and treatment, of the discharge planning process on assigned units. Assists with screening, identification, diagnosis, management and treatment of victims of abuse, neglect, and domestic violence and of mental health and/or substance abuse problems in patients and family members.

• Establishes mutual educational goals with patient and family, providing appropriate resources, incorporating planning for care after discharge. Provides education to physicians and other interprofessional health care team members on mutually identified goals of care and uses knowledge of levels of care, working with patient and family, to ensure discharge disposition is the appropriate level and facilitates transfers.

• Uses knowledge for different levels of care, working with patient and family, to ensure discharge disposition is to the appropriate level and facilitates transfers, Provides brief, goal-directed counseling services to assist patients/families to cope more effectively with the transition.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Consistently documents to reflect completed patient screening/assessment and reassessment upon admission and concurrently as needed. Modifies care based on continuous evaluation of the patient's condition, demonstrates problem-solving and critical thinking, and makes decisions using evidence-based analytical approach. Considers variables that impact treatment plans including diagnosis of emotional, social, and environmental strengths and problems related to their illness, treatment and/or life situation.

• Consistently reviews the total picture of the patient for opportunities for care facilitation and needs for discharge planning. Works with case manager for routine discharge and anticipates/prevents and manages/elevates emergent situations with specific focus given to discharge plan and elimination of psychosocial barriers.

• Collaborates with staff from the interprofessional health care team concerning safety data to improve outcomes and the safe transition of care through effective patient handoffs.

FINANCE ESSENTIAL FUNCTIONS

• Completes timely and thorough assessment on all unfunded patients to identify community resources required for effective transition by demonstrating an effective community resource knowledge base and judgment/ability to effectively select and coordinate available resources, including referrals to regulatory agencies, i.e. CPS/APS.

• Identifies, obtains and utilizes alternative resources to fill gaps in established community resources.

• Guides discharge planning activities for assigned patients and collaborates with the case managers and other members of the interprofessional health care team, as well as patient and family by intervening and coordinating cost-effective, complex discharge planning outcomes and decreased length of stay.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Provides education to hospital physicians, nurses, and other healthcare providers on community resources and psychosocial impact on care needs.

• Identifies areas for improvement based on understanding of evidence-based practice literature. Completes and updates the individual development plan (IDP) on an on-going basis.

• Identifies, initiates and leads evidence-based practice/performance improvement projects based on observations by offering solutions and participating in unit projects and activities.

This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

EDUCATION

• Master Degree in Social Work from accredited University (MSW)

WORK EXPERIENCE

• Three (3) years social services experience in a healthcare setting