Cedars-Sinai Clinical Social Worker in Los Angeles, California
The Clinical Social Worker, Supportive Care Medicine /Palliative Care, is responsible for the development, planning, implementation, and evaluation of all social service-related interventions for patients being followed by Supportive Care Medicine. Specifically, this position will be responsible for identifying patients who have psycho/social needs on an inpatient or outpatient basis. The social worker is responsible for developing patient care goals and treatment plans, as agreed upon by the patient’s care team. The SCM Clinical Social Worker is also available to physicians and other members of the multi-disciplinary care team as a consultant for those patients with complex psychosocial needs and advance care planning.
ESSENTIAL JOB DUTIES:
•Evaluate and implement, with the assistance of the program director and medical director, a high touch social service program for patients with psycho-social needs. Particular focus will be on seniors, catastrophic and chronically ill patients. Specifically:
•Development: Social Service documentation tool/template in EMR for Palliative consults, family counseling and group sessions. IS reports for outcome measurement
•Implementation: triage patients with the Supportive Care Medicine Team; assist in coordination of patient care delivery, including DPA/POLST; document pertinent information in the case management system and communicate to team.
•Implement transitions of care between inpatient Supportive Care Medicine and continued outpatient follow up
•Initiate team care conference to include patient, family and care providers
•Evaluation: evaluate caseload daily and assess achievement of long and short term goals; modify goals with providers and care team based upon patient outcomes; compile and present statistics and reports relating to patient outcomes; document findings in the patients EMR
•Communication: provide follow up and outcome communication to the referral source, IE, PCP, family member, case manager, home health personnel, community social worker, Health Plan, etc.
•Act as social services liaison for the department, particularly in the areas of:
•Palliative Care and Advance Care Planning discussions
•Complex discharge planning
•Referral to agencies which provide supportive services to fragile patients
•Assist in arrangement of community resources (i.e. meals on wheels, transportation services, adult day care, and info-line)
•Assist in long term planning for patients transitioning to an institutionalized setting
•Provide alternatives for patients requiring specific services while lacking insurance coverage
•Act as liaison to Population Health department in regard to chronic disease state management programs
•Assist in the development and implementation of new policies and procedures for the department as they relate to high-risk patient populations and social service interventions.
•Participate in advanced care planning initiatives
•Performs other duties as assigned.
MINIMUM JOB REQUIREMENTS/COMPETENCIES:
This position requires a Masters in Social Work from an accredited school of social work, and current LCSW licensure, 2-5 years clinical social work experience including palliative or hospice care, and discharge planning, with experience in project management preferred. Candidate should also have knowledge of community resources and possess excellent assessment skills. Other requirements include the ability to exercise objectivity and good judgment relating to difficult and emotionally charged situations and the ability to interface effectively with patients, providers, management and employees of the organization as well as facilities and agencies in the community. This position requires an individual who is self-directed, responsible, able to work in diverse groups, and autonomous. PC and strong writing skills, ability to teach others and develop program materials required.