Interviews residents and residents' social support system when appropriate to identify and assess needs, evaluate resources, and work with patient, patient's support system, and the multidisciplinary team to develop a post hospital plan of care.
Provides psychosocial assessment with the patient and develops a post acute plan of care in coordination with the IDT.
Works collaboratively with the residents and residents' social support system to establish and implement a plan of care with multidisciplinary team that meets the patient's identified psychosocial needs.
Intervenes in crisis situations, appropriately and effectively applying crisis intervention theory and skills
Works with the IDT team to assess and evaluate the patient/patient's social support system for the appropriate level of care or environment setting to meet care needs across the continuum.
Maintains current knowledge and researches availability of community agencies and community resources for social, emotional or financial assistance.
Works with IDT to identify problems, recommended solutions and works toward resolution and efficient discharge planning.
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