Social service serp_jobs.h1.location_city

The Discharge / Planner Social Service Coordinator is responsible for providing comprehensive social services which assist patients, clients and their families to find practical ways of overcoming social, emotional and environmental barriers to optimum functioning and attainment of health. The Discharge / Planner Social Service Coordinator alters activities / behaviors to reflect and ensure adequate care and services appropriate to the age of patients served (i.e. neonatal, infant, pediatric, pre-school, school age, adolescent, adult, geriatric).

Essential Functions and Responsibilities

• Interviews hospital patients and their families during the course of an inpatient or observation admission
• Responsible for managing assignment of specified unit or clinic, ensuring that 100% of patients with an identified need have been assessed and evaluated
• Initiates social service plans for patients / clients through professional collaboration with medical, nursing and health care personnel utilizing screening questionnaires, diagnostic assessments and individualized therapeutic care plans
• Coordinates the overall interdisciplinary plan of care for a patient from admission to discharge
• Serves as a liaison between patient / family and healthcare personnel to ensure necessary care is provided promptly and effectively
• Coordinates discharge plans to meet the patients social and emotional needs to ensure a safe and effective discharge
• Assists patients and families in understanding the implications and complexities of their medical situation and its impact on their current lifestyle
• Provides direction in the selection, analysis, summarization and presentation of patient / client and related information for service delivery planning, case conferences and professional consultation
• Provides complex social service intervention to individuals, families and groups ranging from diagnostic assessment, short term counseling, crisis intervention, community resource referrals, client advocacy, support, outreach, follow-up and intra / inter agency consultations
• Provides education and training to introduce or improve coping skills of individuals and families
• Documents services rendered in clinical records
• Responsible for following the required assessment format to ensure all elements for effective discharging have been met with the ultimate goal of reducing readmissions
• Responsible for partnering with the multidisciplinary team to ensure financial resources have been assessed and a determination made to ensure there are limited placement barriers post discharge
• Conducts social service orientation for physician, nurses, and students as appropriate
• Utilizes problem-solving skills to identity and facilitate problem resolution in team functioning
• Participates in staff meetings and education programs for staff and community agencies as assigned
• Assumes responsibility for continuous professional self-development
• Alters activities / behaviors to reflect / ensure adequate care appropriate to the age of patients served (i.e. adolescent, geriatric, pediatric, neo-natal, adult) described in the area / unit age-specific and / or job specific competencies
• Collaborates with multi-disciplinary team members to facilitate the coordination and deliver) of services that assures appropriate treatment plans and continuity of care
• Initiates advocacy / liaison role for patients / clients in referrals to and from community agencies : collaborates with agency and hospital personnel in referral activities : cultivates referral resources
• Interprets impact on client functioning of environmental conditions and family interactions through home visits and outpatient encounters

Job Requirements

Knowledge, Skills & Abilities