Responsibilities/Duties:
- Communicates through direct interview, telephone contact, and written correspondence with potential patients/residents, their families, representatives, and/or agencies representing them who are inquiring about admission to Tamarack Health Medical Center and/or Water’s Edge Care Center and the necessary process.
- Completes a Pre-Admission Assessment on individuals being screened for admission to the Water’s Edge Care Center.
- Completes a psychosocial assessment and re-assessment on patients/residents requiring intervention. This includes geriatric patients/residents with an emphasis on person-centered care and the general patient population.
- Formulates a teaching plan based upon identified learning needs and evaluates the effectiveness of learning; family is included in teaching, as appropriate.
- Provides information to patients/residents/tenants and their families regarding appropriate community resources and assists with referrals. This includes referrals for guardianship or to appropriate agencies in cases of financial, behavioral health, rehabilitative, or social problems that the facility cannot serve.
- Assists with adjustment to the Water’s Edge Care Center and continuing assistance to and communication with the resident, guardian, health care agent, resident representative, family, or other responsible persons.
- Participates in the plan of care for patients/residents, including the potential for discharge, and assists the patients/residents and facility staff in discharge planning at the time of admission and throughout the stay.
- Participates in in-service training for direct care staff on the emotional and social problems and needs of geriatric and chronically ill residents/patients and on methods for fulfilling these needs.
- Promotes and protects patient/resident rights and participates in the investigative process when complaints/grievances are voiced.
- Demonstrates knowledge of discharge planning.
- Identifies and addresses psychosocial, cultural, ethnic, and religious/spiritual needs of patients/residents/tenants and their significant others.
- Consults and communicates with other departments, as appropriate.
- Demonstrates an ability to be flexible, organized, and function under stressful situations.
- Collaborates with the Interdisciplinary Team to establish and facilitate a plan of care for residents at the Water’s Edge Care Center.
- Documents clearly and accurately the Social Services activity in the patient/resident medical record.
- Participates in Plan of Care Conferences, Discharge Planning Meetings, and Medicare Meetings to ensure smooth transition along the continuum of care.
- Completes MDS assessments and CAAs on Care Center residents.
- Hospital discharge planning; coordinating a safe, smooth transition for patients leaving the hospital and returning home or assisting in placement to another care setting.
- Emergency Department follow up on assisting with inpatient placements, transportation, insurance authorization needs, patient/family consultations for community resources/supports, etc.
Education/Experience:
- A bachelor’s degree in Social Work, or a human services field, including but not limited to Sociology or Psychology, is required.
- Current WI Social Work licensure/Credential required
- Minimum one year of supervised social services experience in a health care setting, working directly with individuals preferred.
Professional Skills & Expectations:
- Basic computer knowledge. Knowledgeable regarding the use of electronic and mechanical patient care equipment, office equipment, projectors, audiovisual equipment, and cameras.
- Excellent data management skills.
- Ability to exercise good judgment; excellent problem-solving skills; is creative; adapts to change.
- Must have excellent critical thinking skills.
- Knowledge and sensitivity to cultural differences and gender orientation.
- Advocacy and promotion of Social Justice.
- Knowledge of micro and macro systems.
- Ability to assess from a Person-in-Environment perspective.
- Work will be performed Monday through Friday and at least one weekend per month.
