Piedmont Atlanta Hospital - Atlanta, Georgia
The Piedmont Atlanta Care Management Team consists of 64 staff primarily responsible for discharge planning and transitions of care. The department consists of Registered Nurses, Social Workers, Care Management Assistants, a Department Educator and a Department Assistant. Our leadership team consists of a Director, two Managers and two Supervisors. Care Managment covers all areas of the hospital including ICU, Med/Surg, Mother/Baby, and we have staff dedicated to the Emergency Department. We provide coverage 7 days a week. We work collaboratively with the care team to create and facilitate a discharge plan individualized to meet the specific needs of the patient. The goal is to assess patients within 24 hours of admission and to promptly begin working on discharge planning.
JOB PURPOSE: The Social Worker, MSW strives to promote patient and family wellness, improved care outcomes, access to appropriate hospital and community resources, and manages, supports and develops comprehensive transitional care plans for patients with complex and psychosocial needs in Inpatient and Emergency Department (ED) environments.
1. Assesses, evaluates, plans and coordinates community services
2. Advocates for services to meet the specific patients / family complex needs
3. Conducts high risk assessments within timeline required by departmental and regulatory guidelines
4. Coordinates with Care Manager daily
5. Conducts psychosocial assessments
6. Provides patients / family members with Community Resources
7. Coordinates the transition to post-acute care services (Hospice, Home Health, Skilled Nursing Facility, etc.)
8. Coordinates as needed with other members of the care team
9. Organizes family meetings and/ team conferences
10. Works with the treatment team to provide solutions for complex cases (i.e. Behavioral Health and/or barriers to discharge)
11. Identifies high risk patients based on standardized criteria
12. Coordinates appropriate reporting to legal agencies as needed with respect to abuse and neglect
13. Facilitates the coordination of financial assistance as needed
14. Identifies and documents quality variances and/or barriers to discharge
15. Provides post discharge follow-up as appropriate to ensure continuity of care/services
16. Participates in PHC readmission management initiatives
The above information is intended to describe the general nature and level of work being performed by people assigned to this job. It is not intended to be an exhaustive list of responsibilities, duties and skills required of personnel so classified.
SCHEDULE: Friday-Sunday 7am-7:30pm including holidays as assigned
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MINIMUM EDUCATION REQUIRED:
MINIMUM EXPERIENCE REQUIRED:
MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:
KNOWLEDGE, SKILLS, ABILITIES
At Piedmont Healthcare we embrace diverse ideas, perspectives, and skills to create a collaborative workplace where the best talent wants to succeed. We celebrate differences and recognize that they allow us to care for our community.
Piedmont is a certified Great Place to Work™-- a national designation based on employee feedback about trust, workplace culture and experience. In 2019, Forbes named Piedmont one of Georgia’s 10 best employers and the highest-ranked healthcare provider.