The social worker shall provide patients with the highest practical level of physical, mental, and psychosocial well-being and quality of life. Timely entries in the patients’ charts to include, but are not limited to Social History Evaluation & Assessment, a care plan to address strengths, problems, needs, and interventions, substantiation of psychosocial interventions, progress toward, and/or completion of goals, and transfers.
Completes a comprehensive Psychosocial Assessment for each patient that identifies social, emotional, and psychological needs and strengths. Assesses each patient for discharge. Conducts patient, family, and staff interviews and ensures that relevant MDS sections and Care Area Assessments are completed in accordance with regulation. Participates in the development of a written, interdisciplinary plan of care for each patient that identifies the psychosocial needs/issues of the patient, the goals to be accomplished for those needs and or issues.
Identifies patient discharge goals at admission and documents initial discharge plan. Works with patient/resident, family members/significant others, and interdisciplinary care team through care planning and utilization management throughout the course of the stay to identify strengths and needs to ensure an appropriate discharge plan is formulated.
Makes referrals as needed for post discharge care to appropriate agencies and suppliers. Initiates and participates in completion of Discharge Transition Plan & Discharge. Gather packet materials and orienting the patient/resident and family around the process.
NJ CSW or NJ LSW – 3-5 years of supervised social work experience in health care setting working directly with individuals. Knowledge of accepted standards of practice for social workers in long-term care. Knowledge of biological, psychological, social, emotional, spiritual, practical informational and financial needs and challenges experienced by the patient/resident, family, and caregiver.