Licensed Clinical Social Worker

Description

The Social Worker will provide social services to patients and their families in a timely and efficient manner in order to promote maximum psychosocial functioning and adjustment to dialysis and promote the rehabilitation of the patient. In this vital role, you will help patients understand their rights and responsibilities, and guide them in managing the physical, mental, emotional and financial demands of End Stage Renal Disease. Assist patients with accessing resources for nutritional, emotional, transportation and housing needs. Demonstrate knowledge of government and private insurance programs with the ability to educate and advocate on the patients behalf regarding coverage and desired alterations or needs. Conduct required patient assessment and care planning activities such as assessing new patient psychosocial needs and completing the KDQOL in accordance with company policy and all state/CMS regulations. Collaborate with all hospital staff as a resource regarding social matters and patient advocacy if available. Performs other duties that may be necessary in the best interest of the center, as the description presented is not all-inclusive but only a representative list.

Requirements

EDUCATION: Hold a Master's degree in Social Work (MSW) with a specialization in 

clinical practice.

· Licensed or registered in the state of Texas as required by state regulations.

EXPERIENCE: Must have at least 2 years’ experience as a social worker one of which was in a dialysis facility or transplantation program (preferred).

Essential Duties and Responsibilities:

The goal of Social Services is to promote rehabilitation and psychosocial adjustment and overall well-being in each renal patient. This is to be accomplished through:

1. Assessment of the patient’s needs through direct supportive counseling, or through referrals to other agencies.
2. Collaborate with the patient and health care team to identify effective interventions that will help the patient meet rehabilitation, treatment goals, and improve quality of life.
3. Provides case work for patients and their support system dealing with the special problems associated with end stage renal disease.
4. Participates in team review of patient progress and completes care plans and progress notes as required for patients.
5. Participate in monthly Quality Assessment and Performance Improvement (QAPI) activities and ensure compliance with federal, state, and local laws and regulations.
6. Oversee patient admission, discharge, transfer, and transient processes.
7. Initiate meetings with all new patients and their support members completing psychosocial and other assessments within two weeks of admission.
8. Assesses patient knowledge of kidney disease for barriers that may affect adherence to treatment.
9. Assess and assist with patient’s determinants of health and assist in connecting to resources to improve them, quality of life and program compliance.
10. Completes psychosocial updates-annually more often as needed.
11. Assesses patient awareness of advance directives; assists with accessing advance directive forms/information and facilitates discussion of advance directive wishes, if necessary, with the healthcare team and the patient's family/support persons.
12. Participates in the discussion of patient DNR status in the facility to ensure patient and/or family understand and make an informed decision about their care.
13. Reports on quality indicators related to adherence, such as missed and shortened treatments, quality of life trends, and service recovery.
14. Works with patient, family and health care team to provide education tailored to the patient’s learning style, communication barriers, and needs.
15. Conducts clinic advocacy counseling and conferences with patients, families, and support network in crisis situations.
16. Utilize patient education programs, established social work theory and methods, social work focused interventions, and quality of life measurement instruments as part of the assessment and care planning to address barriers and meet patient treatment goals.
17. Reviews patient rights and responsibilities, grievance information (company and network) and other facilities policies with patient and/or the patients’ representative to ensure patients’ understanding of the rights and expectations of them.
18. Coordinated arrangements with transplant center for referral and screening.
19. Participates in staff in-services and provides staff education and employee grievance management.
20. Support the clinic staff in understanding the emotional, psychological, and behavioral impact of chronic kidney disease on the patient and family.
21. Completes required assessments, surveys, screenings and information required by the ESRD Network including 2728 and 2744 documents as needed.
22. Remain knowledgeable and participatory in ESRD updates and requirements regarding patient social health, wellbeing, rights, and financial implications. 
23. Access transportation services from Medicaid, KHC and private agencies to facilitate patients’ ability to attend treatment and medical appointments.