This position is a unique role that combines clinical social work, complex case management, community outreach & advocacy, program development, and leadership opportunities in caring for our most complex adult in-patients. Successful care coordination and execution of care transitions for complex behavior health and complex medical health requires focused and targeted interventions that are time intense. The average caseload for this role will be 8-10 patients and this role will be expected to consult on another 15 cases with the care management team and hospital staff.
The management of inpatients with complicated medical and psychosocial factors is difficult and often leads to long length of stay, increased hospital costs, and added frustration for the patient, family, and staff. This role will create outcomes for the patient and family by managing complex biopsychosocial and medical comorbidities while navigating systemic gaps in the transitions of care setting.
The goal of this position is to develop effective and focused treatment plans to achieve clinical outcomes and stability to discharge, clarify which patients may require additional consults, referrals, to the ethics committee, reduce cost per case, reduce length of stay (LOS), and provide targeted interventions for our complex population.
On the basis of preliminary risk screening and referrals the clinician will assesses patient and family’s biopsychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope.
Leads the development of a plan of care with the multi-disciplinary healthcare team, patient, family and/or caregiver.
Collaborates the discharge planning activities for complex patients with the care team in order to ensure a timely discharge and to provide appropriate linkage with post-acute care providers.
Strong collaboration with Care Management staff for early notification of complex patients.
Flagging patients using daily reports generated to assist with the identification of at risk patients.
Aligns with families exhibiting complex family dynamics that impact directly on patient care and discharge.
Communicates with the healthcare team regarding the discharge planning status of all patients referred.
Provide education and consultation regarding resources, collaborate to develop a discharge plan and facilitate and monitor its implementation.
Assist patient/family adjust to and cope with the illnesses, diagnosis, treatment options and prognosis.
Through advanced practice skills mobilizes resources to reduce risk for our most vulnerable patients.
Educates patient, family, care team, post-acute options and addresses issues of choice.
Works closely with community mental health, group homes, area agencies, community nursing homes, home health agencies, and air ambulance providers to ensure safe handoff and improve patient satisfaction. Serves as a liaison between the hospital and the community.
Identifies reports and resolves actual and potential delays in service and inappropriate use of resources.
Coordinates referrals to the next level of care i.e., SNF, LTAC, HHC, Hospice, Group Homes, Assisted Living and Air Flight Travel – Air Ambulance.
Appropriately documents in appropriate system, those patients identified as high risk for complex case management and enters all interventions
Identifies and refers potential quality concerns to the Inpatient Complex Case Management Planning Committee who would then refer to the Executive Leadership Committee. Ad hoc members for consultation would include Quality, Risk Management, and Legal Affairs.
Master's degree in Social Work from a school accredited by the Council of Social Work Education is required. Must have current clinical license to practice social work in the State of Michigan.
Licensed to practice as an LMSW in the State of Michigan
The ability to work independently and be self-directed in a variety of stressful and demanding situations is essential; critical decision making, excellent assessments, brief interventions and multi-tasking are only several of the advanced skills required for success.
The ideal candidate will have significant medical social work experience, strong assessment skills, the ability to establish therapeutic relationships quickly, and to relate well to a diverse population. The ability to work independently and be self-directed in a variety of stressful and demanding situations is essential; critical decision making, excellent assessments, brief interventions and multi-tasking are only several of the advanced skills required for success. ?
More than 3 years of social work experience, preferred.
Ability to interview, assess, problem solve and organize. Ability to identify appropriate community resources on assigned caseload and to work collaboratively with patient, families, interdisciplinary team and community agencies to achieve desired outcomes.
Possess interpersonal communication negotiation skills in interactions with patient, families, Physicians and health care team colleagues.
Maintain a current working knowledge of services available in the local community, particularly services available to patient with limited or non-existent payment resources.
Be flexible and committed to the team concept
Demonstrate teamwork, initiative and willingness to learn
Be open to new learning experiences, flexible, open minded and adaptable to change.
Demonstrates customer service values
Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings. Background screenings are performed in compliance with the Fair Credit Report Act.
Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally. Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.
Job openings are posted for a minimum of seven calendar days. This job may be removed from posting boards and filled anytime after the minimum posting period has ended.
The University of Michigan is an equal opportunity/affirmative action employer.
A great university is made so by its faculty and staff, and Michigan is recognized as one of the best universities to work for in the country. The Michigan culture is known for engaging faculty and staff in all facets of the university to create a workplace that is vibrant and stimulating.For two consecutive years, the Chronicle of Higher Education has placed U-M in its "Great Colleges to Work For..." survey. In particular, the university earns high marks for strong relations between faculty and administrators, a collaborative system of governance, strong pay and benefits, and a healthy work/life balance.