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1. Performs high level triage of all patients, with focus on identifying those with complex psych-social or financial issues, placement needs and community service needs within 24 hours of admission.

2. Receives RN Care Manager referrals to social work based on identified Social Work Triggers (see SW Referral Standard Operating Procedure – SOP).

3. Identifies and assesses barriers early in the patient’s stay, formulating a plan with the patient, family, internal and external members of the healthcare team, payers, and community resources. (e.g., LOS barriers to D/C)

4. Assesses patient and family needs for support and community service needs (Meals on Wheels, Sitters, etc.); educates and refers them to community resources, access to services, arrange for appointments and establishes rapport with other agencies.

5. Assesses risk of readmission for specified patient populations and initiates assigned interventions that will enhance the patient’s ability to successfully transition along the care continuum.

6. Identifies the need for, arranges, and participates in family care conferences; participates in interdisciplinary conferences and provides consultation for patient, families, and clinical staff (e.g., attends care conferences/unit rounds/huddles).

7. Identifies and reports avoidable day/variances and/or service delays from established plan of care to leadership.

8. Identifies patient and family preferences, needs and strengths, to foster for the interdisciplinary team in compliance with standards of care.

9. Interviews patient and significant others to assess patient’s psychosocial situation and identifies which family member is the point of contact.

10. Develops discharge plan in direct consultation with patient, family, physician, and health care team.

11. Manages complex cases/situations and intervenes with and advocates for patients and families as plan of care and discharge plan are developed. Complex discharge planning identified from SW triggers (see SW Referral Standard Operating Procedure – SOP)

12. Uses knowledge of insurance benefits and coverage guidelines to maximize appropriate utilization of resources.

13. Documents in the EMR: assessment, plans, interventions, barriers, and reassessments as necessary to facilitate discharge and/or transitions; ensures all pertinent information is transferred to post-acute agency.

14. Works collaboratively with the RN Care Manager, other disciplines, and internal and external members of the healthcare team to ensure a safe, appropriate, and timely transition to the next level of care, taking into consideration the patient’s available resources.

15. Partners with external agencies and facilities to provide continuity of care for patient and family empowerment and independence to make autonomous health decisions.

16. Represents the integrated care management department on various teams and performance outcomes committees and projects.

17. Performs other related duties as required and directed.

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