Social Worker

Department/Location - Hospital - Social Services

FT 72/pp - Benefits Eligible 

Job Summary:

Provides psychosocial support/assistance to MMH patients/families.  Provides intervention to assist in resolving issues interfering with patient care. Further clinical services include: assessment, counseling, education, discharge planning, and service/resource referral.  As an advocate for the patient, social workers at MMH seek to ensure that patients' medical, emotional and social needs are met throughout their hospital stay and upon discharge.  We consider factors such as mobility, accessibility, insurance/payor source, and any potential challenges a patient/family may face upon discharging home or to another medical facility. Crisis intervention tasks include mental health emergencies, ER emergencies for placement (nursing home or psych), and family emergencies that may include report to Child Protective Services or Adult Protective Services. We respond to emergencies related to housing, cost of medications, mental health, need for placement, and any other barriers related to medical care, safety, or daily living. Social workers at MMH help to identify appropriate candidates for the MMH Transitional Care program, drive these referrals to the clinical team, and assist with the discharge planning of Transitional Care patients once they have completed the program.  We work with a variety of departments including med/surg & SCA (Acute Care and Intermediate Care), OB, ER, outpatient PCP offices, and external agencies. 

Supervisory Responsibilities:  None

 Duties/Responsibilities:

• Serves in the discharge planning role in the multi-disciplinary team including Hospitalist, Pharmacist, RN, PT/OT, patient/family members, and others. 


• Accurately collaborates with MD and RN as needs are identified; continuously collaborates with patient/family/ other providers as needed.


• Reports sentinel events or incidents as warranted.


• Reassesses patient in response to changes in condition after intervention as needed & documents in her.


• Provides interventions in a timely & appropriate manner & documents in EHR.


• Communicates with & provides education to patients, caregivers, & family members in a timely manner (using respect & dignity when dealing with death & dying) & documents in EHR.


• Assesses high risk patients within 48 hours of referral.


• Attends interdisciplinary Hospitalist Rounds for assigned rotation; facilitates continuous discussion of discharge need and plans with this multi-disciplinary team at the beside with patients & families.


• Uses interpreters or other resources to prevent language/hearing barriers.


• Demonstrates ability to access information on various types of adoptions and legal guidelines.


• Provides support and linkage to community resources to include WIC, Medicaid, food pantries, substance abuse treatment, behavioral health services, etc. for expecting or new mothers/fathers.


• Demonstrates knowledge of child abuse, endangered adult abuse, and domestic violence; has ability to identify suspected abuse and reports according to legal guidelines


• Demonstrates ability to develop rapport with patients and families with diverse cultures, values, and life experiences


• Provides education to individuals on how systems work and how to access services


• Encourages self-determination of individuals when developing discharge plan


• Provides updates, comprehensive resource list to meet patient needs


• Serves as an advocate on behalf of the patient to access services; ensures patient’s preferences are heard.


• Accepts the possibility of people/family/staff changing their minds.


• Provides education to patients and family and documents in EHR in a timely manner.


• Initiates discharge planning on all high-risk patients and follows up as needed.


• Assess new patients at the oncology center no later than second visit to center


• Provides folder and notebook to all new patients on first visit


• Provides education to family/patients on community resources and financial assistance for health care and medications.


• Provides linkage to patients for assistance in applying for Social Security and Medicaid.


• Provides patient and family support as needed.


• Serves as a community educator as needed.


• Serves as support group or discharge planning discussion facilitator as needed.


• Identifies appropriate candidates for MMH Transitional Care in Hospitalist rounds, communicates the candidate’s needs to the entire clinical team and initiates the referral from start to finish, communicates to the patient/family whether the referral has been approved or denied (if denied, makes alternative referrals), serves as the discharge planner throughout the Transitional Care stay, and can often be called to facilitate interdisciplinary Team meetings when needed.

Required Skills/Abilities:

• Strong verbal communication, listening & counseling skills as well as ability to work from a team approach with other disciplines.


• Comfortable in crisis situations including mental health crisis or situations that warrant report to Department of Children’s Services or Adult Protective Services.


• Ability to consistently multi-task and complete charting in a timely manner despite heavy workload and time sensitive tasks.


• Ability to foster and maintain strong relationships with patients, families, other disciplines, management and our community partners.


• Must be able to operate a computer, copier, fax machine, phone, & automobile.

Education and Experience:

• Minimum Bachelor’s degree in Social Work


• A minimum of 1 years related work experience required


• Must be licensed as a Social Worker in the state of Indiana

Physical Requirements:

• Frequent use of hands, walking, sitting, climbing, standing, reaching, stooping, talking


• Occasionally may have to lift up to 20 lbs