Rehabilitation Social Worker

• Overview The Rehabilitation Social Worker works closely with medical providers, nursing staff, therapy staff, administration, and other members of the interdisciplinary team.
• In this role, the Rehabilitation Social Worker provides comprehensive social work services to residents receiving rehabilitative services after an acute injury or illness.
• These services include, but are not limited to discharge planning, psychosocial evaluation, admissions assessment, crisis intervention actions required, coordination with resident’s internal and external care team, provides advocacy and ensures resident's rights.
• The person holding this role serves as a key member of the interdisciplinary care team.
• Ensures maximum quality of life for assigned residents.

Responsibilities

Job duties specific to this position: Works closely with medical providers, nursing staff, therapy staff, Administration, and other members of the interdisciplinary team. Review new patient admissions to assess the needs of patients and their families. Assess the patient’s social and psychological status to determine mental and emotional stress. Support patients and their families with education about their illness and possible treatment. Provides social work interventions for residents and families in times of crisis, deteriorating health (physical and mental), dealing with disabilities, deterioration of independence and end of life, etc. Help patients understand the financial resources and social support available to them. Assesses resident financial situation, referring to Finance Department as necessary, i.e., Medicaid application. Provides financial counseling as required. Educates resident or client and family/care giver on advanced directives. Work as an advocate for patients and families to help them understand the medical system and the options available to make informed decisions. Identify any mental health concerns and make appropriate referrals. Facilitate communication between patients and other health care professionals. Responsible for discharge planning. Coordinates identified resources and services for timely discharge, involving the residents and family. Ensures complete, accurate and timely documentation. Coordinate/facilitate initial, annual and prn resident and family meetings. Ensure communication with family members not in attendance. Provides effective orientation for new residents/clients and families/care givers. Reviews resident's rights. Reviews significant events/occurrences related to family, finance, and psychosocial behavioral changes with interdisciplinary team. Actively participates as member of interdisciplinary team, sharing psychosocial information and contributing to development of resident care plan. Makes suggestions for interventions and recommendations for revised treatment plans to address social work concerns and issues. Maintains communication with other team members to discuss progress and coordinates resident care efforts. Provides timely social work services following departmental policies, procedures and protocols as well as regulatory guidelines. Comply with all third-party regulations. Keeps current in knowledge of changes to regulations and best practices in social work. Maintains current advance directives and updates quarterly, upon return from hospital, and/or prn. Maintains accurate, complete, and timely, psychological assessments, care plans (initially, quarterly, annually, significant change). Maintains accurate, complete and timely Social Work documentation. Maintains current family contact information, updating annually and prn. Counsels and instruct paraprofessional staff in psychosocial and communications issues and assists with difficult family/care-giver conflicts. Attends conferences/in-services as requested and educates social work staff on learnings. Educates other team members regarding community resources, Medicaid and other social programs and psychosocial issues related to client care. May supervise BSW and MSW students as appropriate. Maintains current knowledge of community resources and new applicable regulations. Actively participates in Quality Assurance Performance Improvement (QAPI) initiatives. Analyzes QA indicators and initiates remedial action as required. Maintains a threshold of errors below target level. Monitors incident reports for indications of care plan modifications and required interventions. Initiates actions as appropriate. Monitors/assesses resident, family and resident's environment for areas where social work planning and interventions can be of assistance. INDPRO