PRIMARY FUNCTION:
To work as a team member of an ambulatory complex care and assist with program development and decision making on merging service delivery and program access issues. To assist patients and families to identify health, social, emotional, and environmental needs and to connect them with available resources/ services through the provision of a full spectrum of longitudinal health and social work services. This position is for Wilmington Pediatrics and Wilmington Family Practice both located in Wilmington Hospital.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
Participates as a member of the Social Care Coordination Center, focused on the addressing needs, supports, barriers, and available community resources to address social care needs of patients.
Understands and leverages multiple electronic systems including Unite Delaware, population health platform(s), electronic medical records, health information networks, state and federal agencies sites.
Provides information on social service programs and state and federal regulations specific to the community.
Employs social determinants of health screenings and develops a plan that will address the needs identified.
Organizes, secures, integrates, and modifies the resources necessary to meet needs.
Works with the patient, family, community, state and federal agencies, inpatient facilities and any other applicable resources, to formulate a plan for longitudinal support and self-management of social needs.
Gathers information regarding the patient's social needs, family support system, financial resources, and available community and governmental resources.
Provides information about resources and options available in the community and coordinates service delivery.
Interprets patient/family needs and provides information concerning the availability and limitations of resources.
Educates and addresses concerns with service delivery including service gaps and access issues.
Maintains pertinent and timely documentation in patient's medical charts and departmental records.
Participates in departmental meetings, multidisciplinary team meetings, case reviews, and contributes to performance indicators for the program.
Supports the departmental educational and staff development initiatives including supervision of undergraduate/ graduate students enrolled in an accredited school of social work, and community health workers.
Performs assigned work safely, adhering to established departmental safety rules and practices. Reports to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.
Performs other related duties as required.
SCOPE, PURPOSE, AND FREQUENCY OF CONTACTS:
Consistent daily contact with patients, families, medical and other professional staff from various hospital departments, community agency representatives, governmental officials, and politicians.
DIRECTION/SUPERVISION OF OTHERS:
Ability to provide supervision to one graduate or undergraduate students at a given time.
May assist in providing direction to community health worker staff
DIRECTION/SUPERVISION RECEIVED:
Director Community Health and Social Care Integration
EDUCATION AND EXPERIENCE REQUIREMENTS:
Master’s degree in social work (MSW) from an accredited graduate school of Social Work
Licensed MSW as required by the state of Delaware
Licensed Clinical Social Worker (LCSW) preferred
Minimum of 2 years of related work experience preferred.
Community visits as needed.
One to two years of direct experience with arranging community services for complex populations
Bilingual language skills are a plus.
KNOWLEDGE, SKILL, AND ABILITY REQUIREMENTS:
Knowledge of Social Work, Crisis Intervention, and Human Behavior theories and practices.
Knowledge of community resources, state and federal programs, and processes for accessing services.
Ability to function as a member of a multidisciplinary team.
Ability to organize and prioritize work assignments.
Ability to evaluate patient needs and create a plan to coordinate care plans.
Ability to evaluate effectiveness of care plan and services.
Ability to learn and understand medical terminology.
Ability to work with minimal supervision, if necessary.
Ability to maintain flexibility and professionalism while working with complex patients who may demonstrate physical or behavioral impairment.
Maintain timely and appropriate documentation.
Understanding of biopsychosocial assessment tools