POSITION PURPOSE

Provides care coordination and discharge planning services to support the medical, psychosocial, and post-discharge needs of patients and families. Assesses barriers to a safe and effective transition of care and coordinates appropriate resources, services, and referrals. Collaborates with patients, families, providers, and the interdisciplinary care team to develop and implement individualized discharge plans, promote continuity of care, and support optimal patient outcomes. Serves as a liaison among the patient, family, healthcare team, and community resources to facilitate communication, address identified needs, and ensure a safe and timely transition to the appropriate level of care.

QUALIFICATIONS

Current licensure in the State of Nebraska as a Registered Nurse (RN) or current Nebraska licensure/certification as a Social Worker with a Master of Social Work (MSW). For RN candidates, Bachelor of Science in Nursing (BSN) preferred. Experience in acute care, case management, discharge planning, utilization management, or care coordination preferred. For MSW candidates, Master of Social Work (MSW) from an accredited program required. Clinical social work licensure preferred when applicable to assigned responsibilities. Previous experience in hospital-based case management, discharge planning, social services, care coordination, or a related healthcare setting preferred. Demonstrated knowledge of discharge planning, community resources, patient advocacy, psychosocial needs, healthcare regulations, and interdisciplinary care coordination. Must maintain all licenses and certifications required for the employee's respective professional discipline.

GENERAL REQUIREMENTS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The requirements listed below are representative of the knowledge, skill, and / or ability required: Ability to add, subtract, multiply, and divide Ability to generate, read, interpret, and take action as it relates to basic financial statements, national and state regulations, safety rulings, operational and maintenance and organizational policies / procedures Ability to write reports and correspondence Ability to effectively present information to patients, families, employees, health care providers, etc... Ability to work cooperatively and communicate effectively to maintain good working relationships with staff and health care providers Ability to work with skill in identifying problems; making frequent decisions regarding method of performance

EQUIPMENT, TOOLS, MATERIALS

Calculator Computer and printer Fax and copy machine General office materials/supplies Information Systems Telephone system

SECURITY/ACCESS

Will have access to the facility 24 hours a day. Will have access to confidential information abiding by the organizations privacy policies and regulations concerning this information. Essential Job Duties and Responsibilities 1. Develops and implements Social Worker/Discharge Planning services, human resources and financial goals and objectives consistent with hospital goals and objectives.

• Assists patients, as needed, with financial planning through referrals to Social Services. Keeps the patient's family informed of patient problems, personal needs, transfers and changes of level assignment. Provides social work consultation to patients, families and staff as requested. Meets with appropriate facility staff concerning patient issues. Acts in compliance with all corporate, State, Federal and other regulatory standards. 2. Meets with the patient and family to review policies on advanced directives, patient rights and non-discrimination as a part of the admission process Conducts and documents a social services evaluation, including identification of patient problems/needs. Provides and arranges for social work services as indicated by patient/family needs. Completes social work assessment and plan documenting patient and family's understanding of and input into development of the plan. Conducts inpatient group therapy sessions. Brief and crisis therapy 3. Maintains communications with Nebraska Department of Health and Human Services caseworkers. 4. Provides information to patient and families about types and costs of services available to enable them to make informed decisions. Maintains a current list of community resources to facilitate referrals. Initiates referrals to agencies when having the social worker make a direct referral will enhance service to the patient/family. Serves as a resource to the Community Case Manager and multi-disciplinary team in providing information and education about community resources. Maintains an effective relationship with collateral agencies and include them in multidisciplinary team conferences when this will improve patient care. 5. Provides emotional support to patients and families and/or groups of patients who may exhibit feelings of anxiety and stress precipitated by illness and hospitalization. Conducts interventions based on needs identified during initial assessment. Advocates for patient and family wishes when appropriate. Provides emotional support to patient and family during hospitalization. Educates patient and family on the intent of the intervention as needed. Inform care team, patient and family of anticipated post-discharge needs. Coordinate with clinical, health education, community health and other staff members in the provision of services to patients. Coordinate with other organizational entities involved in psychosocial and mental health services. 6. Employee will be an instrumental part in integrating behavioral health into primary care. Rounding with physicians 7. Communicates to appropriate staff information about the patient's discharge plan and schedule multi-disciplinary team conferences for patients/families with complex needs or where complex arrangements are required. Assures all documentation complies with applicable regulations. 8. Helps coordinate arrangements for patients with special transportation needs transferring from the hospital. 9. Performs other duties as assigned. 10. Follows HIPAA regulations and ensures that the confidentiality of patients medical, personal, financial records, employee records, and organizational records is maintained. 11. Participates in FCH committees, quality assurance, performance and quality improvement initiatives, and activities which support the facility and department operations. 12. Complies with the state and federal regulatory requirements related to the performance of FCH operations and requirements of the FCH Compliance Program.

Including but not limited to:

The Compliance Policy. Completes all mandatory on-line training annually and as assigned. All department and organization-wide policies. Considers the impact of regulations. 13. Presents self in a professional manner and enhances professional growth and development through participation in education programs, current literature, in-service meetings and workshops. Seeks opportunities for continued growth and performance improvement. Always maintains a professional appearance and manner. Dependable and completes work in a timely manner. Demonstrates an understanding and emphasis on quantity, quality and knowledge of duties and tasks Essential Standards of Service Excellence 1. Abides by Fillmore County Hospital's C.A.R.

E Service Standards which include:

C- COMMUNICATE WITH COMPASSION, COURTESY & CLARITY

We create trust through respectful, professional communication. Greet, Listen, Respect. Greet everyone with eye contact, a smile, and a warm, professional tone. Use the six-foot rule to greet anyone within proximity. Listen actively. Allow others to finish speaking, seek to understand, and respond thoughtfully. Speak honestly and respectfully. Refrain from sarcasm, gossip, or undermining comments. Represent FCH positively. Concerns are addressed privately, not in front of patients or visitors. Praise often and in public. Protect the privacy and confidentiality of all patients and coworkers. Apologize sincerely when appropriate. Manage up during all handoffs and thank patients for choosing

FCH. A- ASSIST EVERY PERSON, EVERY TIME

We go beyond tasks to meet needs with empathy and urgency. See a need, meet a need. Offer help before being asked; never walk past someone who needs assistance. Escort patients and visitors who appear unsure or need direction. Acknowledge delays, explain what to expect, and thank people for their patience. Follow through on commitments and promises.

R- RESPECT EACH OTHER & OUR ENVIRONMENT

We treat every individual and every space with dignity and care. Calm space, caring place. Treat all people with kindness, fairness, and compassion. Maintain a calm, quiet, healing environment. Your demeanor sets the tone. Show respect for cultural, personal, and professional differences. Keep work areas clean, safe, and organized. Clean up after yourself. Protect hospital equipment and property; return items to the proper place. Bring issues forward respectfully and constructively, through appropriate reporting channels.

E- EXCEL THROUGH TEAMWORK & PROFESSIONALISM

We choose behaviors that strengthen our team and uphold our mission. Solutions, not excuses. Be dependable. Show up ready, on time, and prepared for the day. Support coworkers. Offer help and ask for help appropriately. Maintain professionalism during stressful or emergent situations. Bring solutions, not just problems. Contribute to a positive, problem-solving culture. Model professional 'onstage' behavior in all public and patient-facing areas. Dress in a professional manner. Use a complaint as an opportunity to improve. Choose to maintain a positive, solution-focused attitude. 2. Abides by Fillmore County Hospitals Core Values which include: Teamwork Respect Integrity Compassion

ESSENTIAL WORK ENVIRONMENT & PHYSICAL REQUIREMENTS

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Physical Activity Not Applicable Occasionally Frequent Continuous Sitting X Standing X Walking X Climbing X Driving X Lifting (floor to waist level) 30 lbs. 30 lbs. 10 lbs. Lifting (waist level and above) 30 lbs. 30 lbs. 10 lbs. Lifting (shoulder level and above) 30 lbs. 30 lbs. 10 lbs. Carrying objects X Push/Pull 150 lbs. 100 lbs. 0 lbs Twisting X Bending X Reaching forward X Reaching overhead X Squat/kneel/crawl X Wrist position deviation X Pinching/fine motor activities X Keyboard use/repetitive motion X Taste X Talk X Smell X Sensory Requirements Not Applicable Accurate 20/40 Very Accurate 20/20 Near Vision X Far Vision X Not Applicable Yes No Color Discrimination X Not Applicable Accurate Minimal Moderate Depth Perception X Hearing X Environment Requirements Not Anticipated Reasonably Anticipated Occupational Exposure Risk Potential X Bloodborne Pathogens X Chemical X Airborne Communicable Disease X Extreme Temperatures X Radiation X Uneven Surfaces or Elevations X Extreme Noise Levels X Dust/Particulate Matter X Other (List) Shift Requirements 8 hrs/day 10 hrs/day 12 hrs/day Other (varied) Usual workday hours X Not Applicable Yes No Regular, punctual attendance for assigned shifts X Available to work overtime X