Works under the direction of the Manager. Collaborates with the individual, family, physician, interdisciplinary team and payer to plan, organize, coordinate, and monitor the provision of quality and efficacious healthcare services and resources to promote optimal clinical, financial, and satisfaction outcomes. Assists the team with specialized support to patients and families in substance abuse, new diagnosis of catastrophic disease, end of life counseling and advanced care planning, placement education, and complex family dynamics.
1. Conducts comprehensive psychosocial assessments with high risk populations to enhance the plan of care, provide appropriate interventions, and recommendations for follow-up care and services.
2. Practices within the strength-based perspective to identify patient and family strengths and assist patients in building on these strengths to empower them to work toward positive change.
3. Provides counseling and crisis intervention as an immediate support to families, patients and significant others, coping with difficult situations within the acute care setting, as well as a preventative intervention to assist patients and families in improving functional problem solving.
4. Provides and facilitates educational and/or process groups with specific populations in areas of the medical care setting as needed (i.e., newly diagnosed medical illness, coping with grief and loss, life style change)
5. Serves as a resource to patients and families in dealing with and managing conflict that can occur during an acute medical crisis.
6. Facilitates the adoptive process and release of children taken into custody.
7. Assesses the need for guardianship and facilitates the guardianship process.
8. Assumes level of “expert” knowledge of community resources and facilitates connecting patient/families with needed services. Facilitates referrals for patients who have lack of financial resources to support their health care needs, connecting them with resources such as Department of Social Services for Medicaid, prescription support programs, and the like.
9. Assists the medical team in assessment of patients with emotional and behavioral disorders, substance abuse and dual diagnosis patients, provides supportive counseling to these patients, their families and significant others during the hospital stay, and assists them in making follow-up arrangements or transfers to more specialized treatment facilities
10. Assists patients and their families in addressing issues and concerns relating to domestic violence or abusive relationships including facilitating receipt of services to empower safety.
11. Hospital Liaison to assist the Department of Social Services with protective services.
12. Facilitates/Assists patients/families in open discussions regarding advanced care planning to aide in their decision making of end of life care.
13. Utilize complex decision making and problem solving skills that facilitate developmentally appropriate patient outcomes.
14. Acts as an advocate for the patient to ensure their needs are met and their rights protected.
15. Conducts patient and family meetings to discuss various options for next level-of-care including establishing a home support system or alternative living placement plan, which is realistic in relation to the patient’s present and potential function, emotional, and developmental capabilities and is attainable in relation to resources available (i.e., elderly, homeless).
16. Participates in outcomes measurement to enhance and improve the quality of services provided to patients and families.
17. Facilitates completion of Level II PASARRs for patients seeking SNF placement per State guidelines.
18. Facilitates placement of patients who are involuntary commitment, especially transfers to out facility locations.