Social Worker II (LCSW-C) / UMMC Transitional Care Center

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Job ID: 57785
Area of Interest: Professionals
Location: Baltimore, MD US
Hours of Work: 9 - 5:00P
Job Facility: University of Maryland Medical Center
Employment Type: Not Indicated
Shift: DAY
What You Will Do:

 UMMS is currently seeking a Social Worker II (LCSW-C) for our Transitional Care Program that serves the Adult Population.

The goal of the UMMC Transitional Care Program is to assist recently discharged patients with successfully transitioning from UMMC back to their home. The program is designed to assure open, accurate communication and collaboration between the patient and all involved health care providers.

Benefits of Transitional care: 
• Allows patients to better understand and follow discharge instructions
• Helps patients obtain a better understanding of their medications and how to manage them
• Assists patients in communicating with their primary care providers about concerns or changes in condition
• Prevents avoidable hospital readmissions
This program is designed to target vulnerable patients who are at a high-risk for negative post-hospital outcomes.


Job Duties and Responsibilties include:
  1. Obtains or conducts a screening/assessment of patients identified through case finding or referral who are enrolled in the Transitional Care Program. Identifies each patient’s psychosocial situation in relation to the transitional coordination of the medical discharge plan of care.  Monitor the patient’s ability to understand and comply with the D/C treatment plan, with or without the availability of/or assistance of the patient’s identified social support system. 
  2. Directly interviews patients, or patient’s identified social support/significant other, and provides direct oversight of delegated tasks conducted by non-licensed staff to assure needs are screened for social work services, and plans appropriate interventions and goals to reduce risk of non-adherence to medical plan potentially leading to an avoidable hospital readmission. Coordinates the delivery of theses psycho-social services with the care team in accordance with identified goals and plan.
  3. Reviews patient chart and nursing care plans for pertinent medical care or nursing care information.
  4. Provides preventive, protective, or supportive services, including mandatory reporting for patients who are in or who are threatened by situations detrimental to their well-being. Responsible for guardianship procurement as needed in conjunction with mandatory reporting for safety and well-being.
  5. Interprets psycho-social services programs and procedures to patient, program staff and community organizations. Provides direct assistance to patients in accessing services and completing necessary enrollment forms to activate those services. Appropriate delegates these tasks with direct supervision to staff who have demonstrated competency.
  6. Works with the care team and all program stakeholders to develop an optimal transition plan to community services maintaining a timely discharge.
  7. Ensures program transitional psycho-social goals and delegated tasks have been achieved prior to programmatic discharge. Takes corrective action steps to assure desired outcomes are achieved by patient population.
  8. In a collaborative manner or as directed, identifies the need for Social Worker community home, or clinic in-person visitation. Conducts home and community visitation with Community Health Workers routinely. Conducts meetings with patient and/or social support system that result in comfort, decisions, and other important outcomes.
  9. Leads or co-leads department patient care rounds, and actively participate in Interdisciplinary Care Team Rounds in inpatient and ambulatory settings.
  10. Provides consultation to program and care team members as needed on difficult psychosocial cases.
  11. Provides documents as appropriate data from psycho-social screening or assessments, individual contacts, family interventions and discharge planning according to department policy and procedures and State, Federal, and Joint Commission stipulated requirements.
  12. Documents in the medical record in a proficient manner according to organization and program standards, and processes in accordance with licensure and professional standards, in accordance with all State and Federal requirements.
  13. Maintains confidentiality in accordance with hospital and departmental policy and professional standards.  May accompany patients to obtain benefits, entitlement or other services.
  14. Develops a social service network with city, state or other governmental services that serve the needs of the assigned patient population, to assist patients in obtaining such services as, food stamps and other financial supports and assistance in obtaining transitional housing.
  15. Demonstrates a commitment to professional development through participation in relevant in-service and continuing educational programs.
  16. Participates in the training and orientation of peers and program team members in the hospital and/or in the UMMC community.
  17. May participate in the clinical teaching and instruction of undergraduate or graduate social work interns in the field of practice.
  18. Participate in research and publication activities, as needed.
  19. Actively participates in performance improvement activities. 


What You Need to Be Successful:

  1. Master’s degree in Social Work required. Maryland state LCSW-C licensure and credentials is commensurate with clinical assignment. 
  2. Two (2) years social work experience in acute hospital setting is preferred.  This may include internships and paid work experience.

We are an Equal Opportunity/Affirmative Action employer.  All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law. 
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