MISSION STATEMENT

Will deliver and manage excellent services and systems of care for persons with serious mental illness.

POSITION OBJECTIVE

The Social Worker provides general casework services to assigned patients and their families. Maintains overall responsibility for appropriate discharge planning and utilization reviews for existing patients.

POSITION OVERVIEW

This position provides both the discharge and clinical responsibilities of a psychiatric lead social worker. He/she is responsible for completing all the social work documentation including psychosocial assessments, individualized plan of care, on-going coordination and facilitates discharge planning to patients. Meets documentation requirements and functions as a member of the interdisciplinary team. The position also facilitates 1-2 discharge planning or process group a week. 

CLINICAL RESPONSIBILITIES:

Assessment / Reassessment: completes an initial psychosocial and chemical dependency assessment within 72 hours of admission. Documents individual/group interventions daily in the medical record. Completes progress notes including psycho-social reassessment weekly or more often as needed.
Treatment Planning: Assures that treatment plans include appropriate social service interventions within 72 hours and are updated with each change of behaviors and at least weekly.
Interdisciplinary Team (IDT): Actively participates in the daily IDT process and is prepared for the presentation of pertinent information during IDT including revisions of treatment plans, behavior interventions etc. Assures that the interdisciplinary treatment plans are developed in collaboration with the psychiatric team, the patient and the patient’s authorized representative.
Documentation: Writes progress notes on admission, weekly and as needed with new concerns, significant change of behaviors, responses to interventions and when new interventions are needed as well as discharge plans. Completes daily documentation of individual and group interventions.
Patient teaching: instructs patients authorized representatives, conservator regarding treatment plans, discharge planning, achieving target behaviors, treatment and rehabilitation goals and aftercare treatments.
Patient safety Goals: Participates in patient safety goals including but not limited to:
Maintaining safe environment- participates in unit safety rounds
Fall precautions
Elopement precautions
Assault precautions
Acts as patient advocate: Ensures that mentally ill patients maintain their statutory and constitutional rights through patient advocacy and strong knowledge of Lanterman-Petris-Short (LPS) Act. Present cases in the 5250 involuntary hearing conducted by the county superior judge.

Essential Functions:

Coordinate with inter-disciplinary team, patients, families and community resources in provision of social and discharge services.
Presents cases in the 5250 involuntary hold hearing conducted by the San Mateo County Judge.
Work closely with department director, psychiatric medical director, and all clinical staff to meet the psychosocial needs of patients and families.
Helps with the concurrent utilization reviews with out-of-network insurances.
Complete comprehensive psychosocial assessment of patients in timely manner.
Coordinate discharge planning, work as a liaison between the patients, their family, other department and community referrals.
Responsible for the mandated fire arms reporting to the California Department of Justice on admission for patients’ subject for reporting.
Coordinates discharge planning, assists with advance directives, financial and legal issues and maintains documentation of services in the medical record.
Provides process group and individual counseling.
Participates in formulating and updating care plans, development of goals and treatment plans.
Maintain an accurate and timely documentation which complies with federal/state regulations and Seton Medical center policy including but not limited to Initial assessments, Psychosocial/Mental Status Assessments, Weekly IDT, Care Plan, Social Services Progress Notes and Discharge Planning.
Act as a patient advocate and ensure they are informed of their rights, responsibilities and insurance benefits, as well as changes that may affect their rights, responsibilities and insurance benefits.
Provides/facilitate individual counseling to patients and families as needed.
Assists physician with completion of legal paperwork/documentation, mindful of individual county time constraints
Participates in the unit QAPI and safety improvement projects. Reviews indicators for social services on a pre-assigned basis, makes necessary corrections and makes recommendations for improvement.
Assist patients with coordination of complaint/grievance/compliment process. Follows facility policy and procedure and coordinates with program director.
Complete timely assessments and treatment planning
Performs other duties as assigned.
Participates in the theft and loss program. Implements remedial actions as indicated.

QUALITY AND QUANTITY OF WORK

Provides safe, effective and efficient implementation of direct care in accordance with established policies, procedures and standards of care.
Establishes and maintains a therapeutic relationship with patients and their families.
Attends and participates in primary therapy, community meetings, family therapy, and groups.
Assumes overall responsibility for discharge planning, including:
Assessing the patient’s readiness for discharge in coordination with the Treatment Team.
Making appropriate referrals for placement, case management and aftercare services, as assigned.
Developing and maintaining an awareness of community resources.
Provides consultation to patients and their families regarding issues arising from the admission, discharge and/or aftercare plan.
Provide direct treatment for assigned patients and families.

TEAM MEMBER PARTICIPATION

Participates as a team member and provides input via reporting observations, concerns and asking appropriate questions.
Reviews and implements patient treatment plans.
Actively facilitates and participates in multidisciplinary team meetings and treatment planning meetings.
Demonstrates knowledge of management of assaultive behavior techniques.
Provides leadership in facilitating the team process.
Provides education/training to other team members as necessary.

ASSESSMENT

Observes, records and reports patient social and psychiatric behavior.
Completes the Psychosocial Assessment for assigned patients. This includes obtaining necessary data regarding the patient’s social and psychological history.

JUDGEMENT, DECISION MAKING AND INITIATIVE

Demonstrates knowledge and proper use of equipment and supplies.
Promotes and assists residents in developing self-help skills.

RELATIONSHIP WITH OTHERS

Demonstrates a good rapport and cooperative working relationships with all members of the team; responds to co-workers with concern and promotes group morale.

QUALITY IMPROVEMENT

Continually focuses on assigned tasks and seeks and implements improvements as necessary.
Understands and demonstrates the safety program in all activities.
Protects residents from behavior that could damage themselves or others.
Practices universal precautions at all times.

PLANNING AND TIME UTILIZATION

Completes and follows through with tasks and assignments, meeting expected deadlines.

ATTENDANCE AND RELIABILITY

Understands and demonstrates knowledge of all policies associated with attendance.

PROFESSIONAL DEVELOPMENT

Attends all assigned in-service education classes.
Role models excellent professional practice.
Always dresses appropriately and professionally.

Bachelor’s degree in social work, required
Minimum of five (5) years’ experience with social work and discharge planning
At least two (2) years geriatric social work
Exemplary interpersonal skills and ability to work cooperatively as a member of interdisciplinary team
Ability to communicate empathically, respectfully and effectively with patients and their families
Effective time management skills to organize and prioritize workload
Understanding of Medicare guidelines, Title 22 regulatory requirements
Knowledge of DSM/ICD and other medical terminology
Familiarity with behavioral health resources in the community is desired.
Successful completion of applicable background checks is required.