AdventHealth Social Work Specialist FT Days in Davenport, Florida
Social Work Specialist AdventHealth Heart of Florida
Location Address: 40100 US Hwy 27, Davenport, FL 33837
Top Reasons to work at AdventHealth Heart of Florida
Close proximity to Walt Disney World
Various outdoor activities for families and children to enjoy
Beautiful local golf courses available year round
Faith-based work environment
- Monday - Friday, 8:30am - 5:00pm with rotating weekends
You Will Be Responsible For:
Psychosocial Assessment and Interventions
Receives referrals for psychosocial complex problems from the health care team.
Provides assessment and reporting interventions in child abuse/neglect, domestic violence, adult/elderly abuse, child protection and sexual assault, as appropriate
Provides consult services for patients who may possibly lack decision making capacity. Follows the guardianship (temporary/ permanent) policies sand procedures and coordinates with Care Management leadership throughout the process
Provides consult services for foster care and adoptions
Assists the health care team in the patient assessments and placements for mental health services
Facilitates full team discussion including patient and family when ethical dilemmas arise
Completes Initial Evaluation for transition of care needs on all identified patients within one calendar day of admission and documents according to policies and procedures. Interviews patient and involved care givers (as permitted by the patient) as well as a review of the current and past inpatient and outpatient medical record in the Initial Evaluation
Reviews necessary patient information including labs, medications (Pre and post hospital), History and Physical, Therapy notes, ED notes, test results and progress notes
Incorporates the patient/family care goals and preferences as much as possible into the transition of care planning and communicates these goals and preferences to the multidisciplinary team
Incorporate clinical, social and financial factors into the transition of care plan.
Meets with patient/families to discuss realistic and appropriate discharge options and providers of post-hospital care
Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to meet the individual needs of each patient
Identifies and collaborates with the interdisciplinary team and hospital operations to resolve potential barriers to transition of care plan achievement.
Collaborates with the multidisciplinary healthcare team daily in multidisciplinary rounds to efficiently communicate and facilitate high quality patient progression of care and transitions plans
Evaluates the potential for readmissions throughout the patient stay through the monitoring of each patient's readmission risk scores and coordinating readmission mitigation interventions
Assures Social Work consults are completed for specialty services related to psychosocial needs, decision making needs for patients who lack capacity, patient/family adjustment needs and psychosocially complex cases
Develops discharge plan with appropriate contingency plans throughout the hospital stay to enable adaptation to evolving patient care needs and ensure timely care coordination
Escalates issues barriers to appropriate level of Care Management leadership
Assists with End of Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR
Facilitates patient care conferences with multidisciplinary team as needed.
Establishes and documents, based on the predicted DRG and multidisciplinary team member's input, Anticipated Date of Transition (ADOT) and destination and updates, as needed
Actively participates in daily Multidisciplinary Rounds to review progression of care and discharge plan for all assigned patient
Proactively identifies patients who no longer meet medical necessity and escalates potential denials, documents avoidable days, and facilitates progression of care
Collaborates with Utilization Management staff for collaboration on patient status changes and medical necessity discussions
Ensures all patients on assigned unit(s) are moved timely and effectively to appropriate levels of care
Ensures reassessment of discharge needs provided anytime a patient's condition changes and/or the circumstances impacting the provision of post-hospital care changes
Ensures patient notifications are provided and documented in a timely manner for compliance: Important Medicare Letters (IML), Medicare Outpatient Observation Notice (MOON), Patient Choice, and Beneficiary Notice Letter (BNL).
Communicate with patient/family the possible need to pay for services out of pocket
Ensures primary care physician identification and scheduling of follow-up PCP and specialist appointments for post-hospital follow up care
Ensures discharge disposition accuracy and consistency in the EMR on all discharge patients
Serves as a content expert regarding payor information and educates interdisciplinary team and patients/caregivers regarding payor requirements/barriers
Maintains clinical competency and current knowledge of community resources, post-acute care providers and payor requirements to perform job responsibilities.
Participates in department and hospital Performance Improvement activities.
Provides necessary patient care coverage and assistance with other duties as assigned when needed
Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization.
Participates in facility and department regulatory and certification preparations
Bachelor's in Social Work
Minimum two (2) years experience in hospital/medical social work
EDUCATION AND EXPERIENCE PREFERRED:
Masters in Social Work
Care Management discharge planning experience
Knowledge of state and federal guidelines pertinent to care management
The Social Work Specialist intervenes with patients who have complex psychosocial needs, require assistance with eligibility determination for social programs and funding sources and qualify for community assistance from a variety of special funds and agencies, and/or require assistance with transitions of care or discharge planning. In addition, offer crisis intervention to patients and families with psychosocial needs and coordinates and facilitates the development of a discharge plan of care for high-risk patient populations. This role will receive referrals for individuals from at-risk populations from interdisciplinary team members (including physicians, RN Care Managers, staff nurses, and other members of the care team). The Social Work Specialist, in collaboration with the patient/family, care manager nurses, nurses, physicians and the interdisciplinary team, ensures patient-centered care coordination through the continuum of care. The Social Work Specialist ensures efficient and cost-effective care through appropriate resources monitoring, and clinical care escalations.
This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.
Category: Case Management
Organization: AdventHealth Heart of Florida
Shift: 1 - Day
Travel: AdventHealth Heart of Florida
Req ID: 21035704
We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.