Evaluates and treats patients of all ages, modifying plan of care as appropriate. Serves as a role model in delivery of professional services and as a clinical resource for staff and students.Demonstrates ability to perform patient transfers with assistance as needed from bed, chair and floor, if applicable. Is aware of and demonstrates safe and appropriate body mechanics to reduce the risk of injury to self, staff and patients.Demonstrates respect by treating our patients and each other with dignity and respect, being empathetic and caring, and staying fully engaged with those who need our services.Designs an appropriate plan of care that integrates goals, treatment, outcomes, and discharge plan. Adjusts the care based on patient response and available evidence.Educates patients, family, caregivers, students, and other health care providers using relevant and effective teaching methods.Evaluates clinical findings to determine physical therapy diagnoses and outcomes of care.Performs examination, selecting reliable and valid examination methods relevant to the chief complaint, results of screening, and history.Produces documentation in accordance with the Clinical Process Policy (CTSCP67).Screens patients using procedures to determine the effectiveness of and need fortherapy services, if appropriate.Uses support personnel according to legal standards and ethical guidelines. Monitors the care delivered by support personnel and provides regular feedback.Evaluates and implements intervention plans utilizing activities that are functional in nature and take into consideration the functional and emotional needs of the patient/family. Modifies approach in response to patient behavior and performance.Utilizes standardized outcomes measures in a uniform manner to ensure functional performance is accurately reflected.Completes documentation in accordance with regulatory and organizational standards.Collaborates with patient, family and significant others throughout the rehabilitation process and provides education/family training as necessary.Provides supervision to PTA and rehabilitation technicians in accordance with regulatory agencies.Clearly communicates patient performance, change in status, activity/transfer recommendations, and recommendations for discharge disposition and equipment required for the next level of care with the medical team.

The Social Worker for Community Health Initiatives provides professional services to clients and their families eligible for the Healthy Beginnings Services in order to meet identified psychosocial, emotional, financial and environmental needs. This SW will also serve patients/families on board the Mobile Health Clinic performing Social Determinants of Health and providing appropriate referrals/resources. The social worker provides psychosocial assessments, supportive counseling, emergent crisis intervention appropriate to setting, financial resource information, environment enhancements, advance directive planning and referrals to community agencies for clients and their caregivers/families in the client's home, mobile health clinic (MHC), or other settings. Using an interdisciplinary team approach, the social worker ensures clear communication and helps to facilitate care transitions. The social worker identifies and implements interventions at the individual and systemic levels and provides expertise to high risk clients across the continuum. The social worker works collaboratively with the multi-disciplinary team to support the RN performing at the highest level of their license in addition to maximizing the social worker's specialized training to address complex cases. Social Services are provided as part of a collaboration with interdisciplinary teams in adherence to the NFP model, and to policies, procedures, guidelines, and standards of NFP and of the Carle Health System.Involves client/patient/family in case planning decisions.Provides social work intervention to clients and their families eligible for the Healthy Beginnings and/or Mobile Health Clinic services.Helps to facilitate care transitions, referrals to scoial services, and other specialits when needed.Keeps the director/manager informed of problematic cases, especially those involving legal or risk management issues.Provides assistance and advocacy to clients in obtaining financial resources and government entitlements.Develops and maintains tracking system of social services referrals /outcomes.Provides information and counseling for advance directives and health care power of attorney.Provides social work intervention to patient/families eligible for the NFP Program.Responds to referrals from healthcare team members to identify available services for case specific needs.Collaborates with nurse home visitors / supervisors / mobile health clinic staff to meet the needs of high risk populations.Details (direct or incidental) possible to enhance service/care is communicated across service lines and among disciplines.Documents all client interactions, significant observations, interventions, and actions taken in the client's medical record in an appropriate and timely manner.Formulates, develops, and implements a plan utilizing appropriate social work interventions. Provides education and counseling to clients and families around issues related to adaptation to the client's illness and/or life situation. May utilize crisis intervention, brief and long-term individual, group, and family therapies.Assists clients and their families in establishing goals and outcomes through therapeutic relationships by providing education, support, and referral resources.Assesses physical, emotional, social, spiritual, and environmental needs of clients and their families as they relate to the NFP domains.As requested/required, participates in community coalitions and other community organizations in support of NFP as well as promotes public awareness of Healthy Beginnings Services and the Mobile Health Clinic.Facilitates education/training modules to assist RN staff managing basic social work needs.