Under the general direction of the Director of Care Management, performs those accountabilities relevant to addressing psychosocial concerns of patients and families, disc discharge planning coordination and community agency referrals. Creates optimal outcomes for the patient and family by managing complex psychosocial and economic co-morbidities. Through advanced practice skills mobilizes resources to reduce risk, and serves as ambassador between hospital and community.
- MISSION AND VALUES: Be a visible model for the hospital's mission and values. Exhibit the values and philosophy of SSM Health Care and St. Mary's Hospital Medical Center in daily activities and perform job functions in accordance with hospital policies. Respect the privacy and dignity of individuals, courteously provide them with services and information and recognize the patient care mission of the hospital, its spiritual heritage, and its overall philosophy.
- CliNICAL: ASSESSMENT: Complete initial and ongoing assessment specific to psychosocial, psychiatric, crisis intervention and discharge planning needs of patient and family/significant others across the age continuum. Identify physical, social, psychological, cultural and spiritual variables which affect the patient and family/significant others across the age continuum to promote effective discharge outcomes. Determine knowledge and skill levels of patients and families/significant others for all age groups and incportate this information into the discharge plan. Complete psychiatric assessments for identified patients who present with mental health issues. Based on assessment, develops and documents a discharge plan. Complete psychiatric assessments for identified patients who present with mental health issues in the Emergency Department. Refer appropriate cases for admission or community crisis support as it relates to discharge from the Emergency Department. Case find through the use of high risk screens and communication with ED providers. Identify indicators of abuse or neglect and intervened per regulatory requirements. Intervene to prevent social admissions as appropriate, e.g. Home Health, 24 hour caregivers. Coordinate discharge plan in conjunction with patient and family/significant others. Present options to patient and family/significant others to address their needs and assist them with decision-making process. Coordinate information and referrals for financial and community resources. Verify insurance converge for post-hospital services, if possible. Assist patients and families/significant others with completing Advanced Directives-Power of Attorney for Health Care. Coordinate patient care with inpatient and communicate issues assessed and possible interventions. Participates in care coordination rounds. Facilitate group therapy, planning, assessment of effectiveness of therapy. Coordinate with referral agencies and outreach. Coordinate, facilitate chapter 51, commitments, emergency detentions and assist with director's hold.
- CUSTOMER RELATIONS: Consistent with the hospital vision to surpass the expectations of those who depend on us, demonstrates a customer focus while providing service (e.g., maintain confidentiality, is courteous to all customers--patients, families and all other hospital staff-addresses and follow up on departmental customer concerns). Provide excellent customer services. Know and practice hospital identified customer service behaviors. Identify responsiveness to customer needs as a personal priority.
- QUAliTY: Support the importance of Continuous Quality Improvement. Participate in department quality improvement projects. Participate in hospital wide interdisciplinary quality improvement projects, as needed. Make suggestions for continuous improvement in departmental procedures and processes specific to the PM/Night role.
- HUMAN: SELF DEVELOPMENT: Be a self-learner and foster learning in others. Pursue continuing education in area of expertise/leadership. Achieve and maintain hospital wide and department identified competencies. Participate in educational offerings provided by the hospital. Attend all mandatory training programs. DEPARTMENT STAFF MEETINGS: Actively participate in departmental staff meetings. Participate in shared governance and decision-making. POliCIES AND PROCEDURES: Comply with hospital and department policies and procedures. Comply with all quality and regulatory standards. RECOGNITION & SUPPORT: Recognize, value, and build on differences and commonalities in people. Recognize, acknowledge and support the contributions of all co-workers. OTHER: Participate in education and training of new department employees and students as needed. Provide scheduled coverage for weekends. Participates in hospital wide orientation process specific to departmental role. Maintain work area in a clean and orderly manner.
- TEAM WORK: Exhibit an approachable, interactive style in relationships. Recognize and value contributions of coworkers. Use team process and consensus building for decision-making. Act with integrity and honesty, being willing to trust others and able to engender trust.
- PLANNING: Projects, department activities and programs are based on the SSMHC/WI strategic plan. Participate in identifying new department opportunities that contribute to the strategic plan and departmental goals. Participate in the department process for accomplishing and measuring outcomes.
- FISCAL: Effectively manages work hours to stay within budgeted FTE hours.
- Psychiatric assessment, risk factor analysis, and discharge planning.
- Group therapy dynamics.
- Crisis, conflict and stress management.
- Problem-solving, root-cause analysis, and principles of clinical performance improvement/understanding family dynamics.
- Participate in care coordination rounds.
- Facilitate family meetings.
- Other duties as required.
- Master's degree in Social Work from an accredited school
- Health care law and regulations related to acute care and the immediate post-acute continuum.
- Computer skills.
- State of Wisconsin Licensed Clinical Social Worker (LCSW) preferred or Certified Advance Practice Social worker (CAPSW)
- Previous medical/behavioral health social work in an acute care setting preferred.
St. Mary's Hospital – Madison –
St. Mary's is a 440-bed tertiary referral hospital offering inpatient and outpatient treatment and diagnostic services in primary care and nearly all specialties. Medical/surgical areas of special focus include the Family Birth Center, pediatrics, Neuroscience Center, geriatrics, orthopedics, emergency services and more. St. Mary's is affiliated with the University of Wisconsin School of Medicine's three-year family practice residency program. Since 1912, St. Mary's has provided service to much of south-central Wisconsin including Dane County and 17 other nearby counties. In the growing city of Sun Prairie, northeast of Madison, St. Mary's Emergency Clinic provides services to more than 30,000 residents.