Upvote
Downvote
Inpatient Social Work, Care Transitions
Share Job
- Suggest Revision
- Participates in inter-disciplinary and inter-agency collaborative efforts to identify and coordinate care, treatment and post-acute care needs.
- Provides patient/support system education and resources regarding options for care and completes relevant referrals to health agencies, mental health facilities, counseling services, social agencies, post-acute care providers, and disease or condition-specific resources in an effective and timely manner based on the patient condition/needs to minimize delays in patient receipt of services.
- Demonstrates expertise in facilitating end-of-life discussions and issues, including goals of care, hospice, and palliative care.
- Demonstrates expertise in addressing advance directives, power of attorney, health care representative, and guardianship issues and serves as a resource to the interdisciplinary health care team consulting with Legal as needed.
- Identify and utilize appropriate interventions to address barriers to care/discharge; locate resources; identify options and available supports; facilitate referrals and applications to government/community agencies; advocate for access to resources; coordinate referrals and/or placement plans; assist patient and family to emotionally prepare for transitions; prevent readmissions for non-medical reasons.
Active Job
Updated YesterdaySimilar Job
Relevance
Active