AdventHealth Celebration Health was designed as a Mediterranean resort-style facility to serve as a cornerstone of health in Disney’s planned community of Celebration, Florida
The hospital consistently delivers a state-of-the-art healing environment to residents of Osceola, Orange, Polk and Lake Counties, as well as to visitors from across the United States and the world. All within a 'living laboratory' of groundbreaking, research-driven clinical solutions that integrate mind, body and spirit in the defeat of illness and disease
Monday - Friday, 8:00am - 4:30pm with weekends as needed
You Will Be Responsible For:
Psychosocial Assessment and Interventions
Receives referrals for psychosocial complex needs from the health care team.
Provides assessment and reporting interventions in child abuse/neglect, domestic violence, adult/elderly abuse, child protection, sexual assault, and human trafficking as appropriate
Provides consult services for patients who may possibly lack decision making capacity. Follows the guardianship (temporary/ permanent) policies and procedures and coordinates with Care Management leadership throughout the process
Provides consult services for foster care and adoptions
Assists the health care team in the patient assessments and placements for mental health services
Facilitates full team discussion including patient and family when ethical dilemmas arise
Promotes the understanding and use of advanced directives and ensures patient preference and care goals are followed
Completes Initial Evaluation for transition of care needs on all identified patients within one calendar day of admission and documents according to policies and procedures. Interviews patient and involved care givers (as permitted by the patient) as well as a review of the current and past inpatient and outpatient medical record in the Initial Evaluation
Reviews necessary patient information including labs, medications (Pre and post hospital), History and Physical, therapy notes, ED notes, test results and progress notes
Incorporates the patient/family care goals and preferences as much as possible into the transition of care planning and communicates these goals and preferences to the multidisciplinary team
Incorporate clinical, social and financial factors into the transition of care plan.
Meets with patient/families to discuss realistic and appropriate discharge options and providers of post-hospital care.
Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to meet the individual needs of each patient
Identifies and collaborates with the interdisciplinary team and hospital operations to resolve potential barriers to transition of care plan achievement
Collaborates with the multidisciplinary healthcare team daily in multidisciplinary rounds to efficiently communicate and facilitate high quality patient progression of care and transitions plans
Evaluates the potential for readmissions throughout the patient stay through the monitoring of each patient's readmission risk scores and coordinating readmission mitigation interventions
Assures Social Work consults are completed for specialty services related to psychosocial needs, decision making needs for patients who lack capacity, patient/family adjustment needs and psychosocially complex cases.
Develops discharge plan with appropriate contingency plans throughout the hospital stay to enable adaptation to evolving patient care needs and ensure timely care coordination
Escalates issues barriers to appropriate level of Care Management leadership
Assists with End of Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR
Facilitates patient care conferences with multidisciplinary team as needed.
Establishes and documents, based on the predicted DRG and multidisciplinary team member's input, Anticipated Date of Transition (ADOT) and destination and updates, as needed
Actively participates in daily Multidisciplinary Rounds to review progression of care and discharge plan for all assigned patients
Proactively identifies patients who no longer meet medical necessity and escalates potential denials, documents avoidable days, and facilitates progression of care
Collaborates with Utilization Management staff for collaboration on patient status changes and medical necessity discussions
Ensures all patients on assigned unit(s) are moved timely and effectively to appropriate levels of care
Ensures reassessment of discharge needs provided anytime a patient's condition changes and/or the circumstances impacting the provision of post-hospital care changes
Ensures patient notifications are provided and documented in a timely manner for compliance: Important Medicare Letters (IML), Medicare Outpatient Observation Notice (MOON), Patient Choice, and Beneficiary Notice Letter (BNL).
Communicate with patient/family the possible need to pay for services out of pocket.
Ensures primary care physician identification and scheduling of follow-up PCP and specialist appointments for post-hospital follow up care
Ensures discharge disposition accuracy and consistency in the EMR on all discharge patients.
Serves as a content expert regarding payor information and educates interdisciplinary team and patients/caregivers regarding payor requirements/barriers.
Maintains clinical competency and current knowledge of community resources, post-acute care providers and payor requirements to perform job responsibilities.
Participates in department and hospital Performance Improvement activities.
Provides necessary patient care coverage and assistance with other duties as assigned when needed.
Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization.
Participates in facility and department regulatory and certification preparations.
Clinical Social Worker, Licensed, serves as a preceptor
Clinical Social Worker, Licensed, participates in process improvement projects at the facility, division or corporate level.
Clinical Social Worker, Licensed, participates in ongoing professional committee, board or conference involvement
Clinical Social Worker, Licensed, may provides supervision of MSW and SW students
EDUCATION AND EXPERIENCE REQUIRED:
Master’s degree in Social Work
Minimum five (5) years experience in hospital/medical social work
EDUCATION AND EXPERIENCE PREFERRED:
Care Management discharge planning experience
Knowledge of state and federal guidelines pertinent to care management
LICENSURE, CERTIFICATION, OR REGISTRATION Required:
Clinical Social Worker License
LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:
Case Management certification highly desirable - ACM (Accredited Case Manager), CCM (certified Case Manager)
The Clinical Social Worker, Licensed, intervenes with patients who have complex psychosocial needs, require assistance with eligibility determination for social programs, funding sources and qualify for community assistance from a variety of special assistance programs and agencies, and/or require assistance with transitions of care or discharge planning. In addition, offer crisis intervention to patients and families with psychosocial needs and coordinates and facilitates the development of a discharge plan of care for high-risk patient populations. This role will receive referrals for individuals from at-risk populations from interdisciplinary team members (including physicians, RN Care Managers, staff nurses, and other members of the care team). The Clinical Social Worker, Licensed, , in collaboration with the patient/family, care manager nurses, nurses, physicians and the interdisciplinary team, ensures patient-centered care coordination through the continuum of care. The Clinical Social Worker, Licensed, ensures efficient and cost-effective care through appropriate resources monitoring and clinical care escalations. The Clinical Social Worker, Licensed, is under the general supervision of the Care Management Supervisor or Manager and is responsible for patient evaluations of post-hospital needs; development of a transition of care plans and initiation of the implementation of the transitions of care plans prior to the discharge of the patient.
The Clinical Social Worker, Licensed, is responsible for optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, readmission prevention and length of stay management. The Clinical Social Worker, Licensed, communicates daily with the interdisciplinary team during daily multidisciplinary rounds. Care coordination, discharge planning, transitions of care planning and are core competencies of this role. The Clinical Social Worker, Licensed, facilitates the collaborative management of patient care across the continuum, intervening to remove barriers to timely and efficient care delivery and reimbursement. The Clinical Social Worker, Licensed, provides education to nurses, physicians and the interdisciplinary team on issues related to utilization of resources, medical necessity, CMS CoP for Discharge Planning and care coordination. The Clinical Social Worker, Licensed, is knowledgeable of post-hospital care and services available to the patient including, but not limited to the following: Home Health, Infusion Services, Durable Medical Equipment, Palliative Care, Hospice, Outpatient Services, Transitions of Care Clinics, Transitional Care supportive programs and clinics, follow up appointments, Skilled Nursing Facilities, Rehabilitation Services and Facilities and Community-based Organizations. The Clinical Social Worker, Licensed, adheres to departmental and system goals, objectives, policies and procedures and ensures quality patient care and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.