Medical Social Consultant - UI Health, Complex Care

Report to the Director of Health Social Work and take direction from leadership under the Department of Health Social Work. The Medical Social Consultant provides counseling, comprehensive, psychosocial assessment and related functions for patients identified as needing Social Work support or intervention. Serves as collaborative partner with the members of the multidisciplinary healthcare team to facilitate an appropriate transitional care plan. A progression of responsibility is evident in this series and ranges from simple, routine, and repetitive duties performed to duties that are complex and highly diversified requiring the exercise of discretion and independent judgment performed under administrative direction. Duties Responsibilities: Social Work-related tasks Meets directly with patient/family to perform a comprehensive assessment including social, emotional, cultural, mental status, environmental and financial circumstances in conjunction with interdisciplinary assessment of the patient. Recommends a plan of intervention based on mutually established goals. Conducts and documents initial psychosocial assessment, appropriate interventions, and expected transition in a comprehensive, clear, timely and legible manner, addressing: Reactions to illness and different abilities, especially the chornically and terminally ill. Adjustment to the medical setting and compliance with the treatment plan. Adjustment/coping with the post-hospital/clinic care needs and linkage to community resources Facilitates health care surrogacy and/or guardianship process, for patients, deemed non-decisional by medical team, in accordance with Illinois Health Care Surrogate Ace and hierarchy. Leads efforts to find family and/or surrogate decision maker for patients. Collaborates with complex service line and the legal department to file for Illinois State guardian when necessary. Coordinates groups for supportive interventions and educational opportunities Addresses financial issues related to insurance coverage and payment, refers to Financial Case Management Unit/Insurance Verifiers Conflict resolution, management of complex family dynamics impacting plan of care and discharge planning, coordination of complex clinical case conferences Investigation, management and reporting of suspected abuse or neglect of minor children and vulnerable adults. Facilitates involvement of Illinois Department of Children and Family Services (ILDCFS). Facilitates involvement of Illinois Department of Aging. Identifies, reports, provides intervention, offers safety planning, and documents cases of suspected intimate partner violence/domestic violence of adults. Facilitates involvement of Chicago Police Department when deemed necessary. Assesses for depression and suicidal ideation using validated tools. Addresses psychiatric symptoms and substance use disorders Provides supportive care for patients considered for hospice/palliative care and participates in family meetings to discuss goals of care and end of life planning Address needs for patients who are unhoused Performs assessments of the physical environment and adequacy of support systems to prevent a crisis and/or hospitalization Quality Improvement committees and other committees where Social Work involvement is warranted. Coverage/Training/Clinical Performance Activities Provide cross coverage to other clinics and inpatient medical units as assigned. Assist with training new staff and student interns. Assists in collection and reporting of financial indicators including LOS, avoidable days, resource utilization, discharge barriers, cost per case, readmission rates, denial. Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients/units, including financial, clinical, quality and patient satisfaction data. Collects data for discharge delays, over-utilization of resources, avoidable days and other data for specific performance and/or outcome indicators. Participates in the development, implementation, evaluation and revision of case management tools in collaboration with healthcare team. Assumes responsibility for professional development and social work CE requirements by participating in workshops, conferences and/or in-services. Based on Program needs to develop and lead Groups or educations sessions. Provide any functions that may be considered appropriate to the role or services as a Social Worker. Maintains competency for Clinical Licensure (LCSW). Psychiatric transfers Other Duties as assigned Inpatient Medical Social Work Manages discharge planning through placement coordination and resource utilization. Actively participates in the stages of discharge planning and ensures that the plan of care is coordinated, facilitated, and effectively communicated to the Physician, healthcare team, patient/designated caregiver(s). Attends daily Multidisciplinary Rounds (MDRs) or Unit/Clinic based rounds. Utilize appropriate software to cultivate resources mapped directly from Patient’s medical, social, and cultural needs and insurance coverage, financial status, geographical preference, and physician recommendations. Coordinates action plans when barriers are present to facilitate resolution. Coordinates discharge planning to ensure a timely discharge (placement or return to community) through early identification, assessment, and intervention for post-medical center care needs, to ensure that the patient is discharged when medically ready for: Other Hospitals Rehabilitative facilities Extended care facilities Sub-Acute Care or Group Homes Psychiatric and Chemical Dependency Care Return to home or other living arrangement Escalates to supervisor/director when barriers are present to facilitate resolution. Proactively identifies and resolves delays and obstacles to discharge. Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues and system problems. Demonstrates knowledge of community resources and an ability to connect patients and families with these resources. Acts as an advocate on behalf of the patient who requires assistance to gain access to needed information, resources, or services. Reviews clinically high-risk cases and submits for review at weekly Clinical High Risk meeting, attended by Physician Advisor, Risk, Ethics and Discharge Planning. Engages clinic providers and staff through regular contact/updates and attendance at clinic/provider meetings. Facilitates appropriate transitions of care by engaging the clinical team upon admission and discharge and referring the patient to ambulatory social work and care coordination as appropriate. On- Call responsibilities (Does not apply for Extra Help) On-Call duties to provide phone consult, coordinate discharge planning, communicate regarding reporting activities, etc. to all medical center areas after normal business hours and follow up with documenting on-call activities. During disaster the on-call person would help activate phone triage list to arrange help as needed during an internal or external disaster