Northern Light Maine Coast Hospital

Department: Care Management

Position is located: Northern Light Maine Coast Hospital

Work Type: Full Time

FTE: 40 Hours per Week

Work Schedule: 8:00 AM to 4:30 PM

Summary :

Reports to Care Management/Quality Leader. Is responsible for providing social work activities for the hospital. Assesses, plans, implements and evaluates the needs of patients for discharge planning. Assumes a leadership role with the interdisciplinary team to achieve optimal clinical and resource outcomes for the pre-hospital, acute and post-hospital phases of care.

Responsibilities :

• Identifies patients requiring services in collaboration with Care Managers including risk identified patients. • Assists patients and/or their families to adjust to hospitalization. • Gathers information about patient's social, psychological, cultural environment and/or financial situation. • Assesses and utilizes information to help counsel patients and their families to deal with identified situations. • Assists patients and families to identify access needed community resources. • Coordinates nursing home transfers and admissions, assists with coordination of appropriate home health referrals. • Assists with financial applications, when appropriate. • Assists with and works in conjunction with Care Managers. • Acts as a liaison to post-hospital providers. • Acts as a liaison with community resources and families. • Identifies resources to facilitate the patient's transition to alternate levels of care, as appropriate. • Develops, implements, and facilitates a discharge plan of care that provides most appropriate level of care and efficient use of resources. • Demonstrates creativity in development of feasible discharge plans to meet the needs of patients. Thinks "big picture". • Monitors and evaluates patient's response to interventions/revises discharge plan, as indicated. • Identifies barriers to discharge and assists with their resolution. • Maintains appropriate and complete documentation of evaluation needs, discharge plan, and updates/changes to plan. • Develops and maintains a collaborative relationship with physicians, hospital departments, community service providers, reimbursement entities, and family/caregivers to facilitate effective communication. Acts as a liaison, when appropriate. • Serves as an advocate for patient and families in the resolution of psychosocial issues related to established plan of care. Refers to Care Mangers, as appropriate. • Consults other departments, as appropriate, to provide for an interdisciplinary approach to the patient's needs. • Performs all aspects of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors. • Documents to meet current standards and policies. • Reviews, monitors, and collects quality data from patient records in accordance with identified quality studies, as indicated. • Demonstrates the ability to be flexible, organized and function well under stressful situations. • ER assessments/assistance as able for continued care plans • Work with agency regarding SUF waiver patients • Works on hospital teams as directed and provide input to same • Performs such related duties not listed herein but deemed in the best interest of the hospital.

Other Information :

Competencies and Skills

• Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan.
• Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of diversity, inclusion, empowerment and cooperation.
• Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved.
• Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.

Credentials

• Required Licensed Social Worker

Education

• Required Bachelor's Degree

Working Conditions

• Potential exposure to abusive and/or aggressive people.
• Potential exposure to diseases or infections.
• Need to drive to perform responsible duties.
• Potential exposure to hazardous materials.
• Potential exposure to noise levels being uncomfortable.
• Potential exposure to noxious odors.
• Potential exposure to very hot or cold temperatures.
• Work with computers, typing, reading or writing.
• Lifting, moving and loading 20 to 30 pounds.
• Prolonged periods of sitting.
• Alternate shift schedules (day, evening, nights, weekends).
• Prolonged periods of standing.
• Prolonged periods of walking.