The medical social worker is responsible for working in a team structure with the RN Case Manager in order to effect overall care coordination with the emphasis on psychosocial assessment and intervention, complex discharge planning, knowledge of community resources, appropriate documentation in the medical record and networking and collaborating with other hospital disciplines and community agencies. The social worker assists the patient, family/guardian, and all members of the healthcare team in the transition of care/complex discharge planning process. Social worker is accountable for assessments and intervening with patients and family, by applying critical thinking skills to monitor psychosocial status and issues that impact the clinical progression and transition/discharge planning for the patients, coping and decision making. Demonstrates positive communication and interpersonal skills with patients, families and coworkers and participates in patient and family conferences as needed. The social worker may be called on to manage behavioral emergencies beginning in the Emergency Department and continuing through the continuum of care as a back up to the ED social worker.
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