Rehab and Transitional Care Center Social Worker
Join us in Caring for the Most Important People on Earth™. We reward hard-working professionals with competitive pay, great benefits, and career growth opportunities.
Provides social work services to patients and families in the rehabilitation and Transitional Care Center setting from admission through discharge. Assesses psychosocial needs, supports adjustment to illness and changes in function, and coordinates discharge planning with the patient, chosen supports and interdisciplinary team. Promotes patient choice, continuity of care and access to services needed for the next level of care.
St. Ann’s Community Offers:
Salary range $58k - $66k gross/year
Full time (37.5hrs/wk.)
Health, Dental, and Vision
Tuition Reimbursement, and Scholarship Opportunities
Employer-paid life insurance
403(b) with company contribution
Catholic school tuition assistance
Job Description:
Admission and Psychosocial Assessment
• Welcomes patients and families, explains the social work role and short-term rehabilitation process, and assists with adjustment to the unit.
• Reviews assigned admission information, patient rights, communication preferences and facility procedures; addresses questions and refers concerns to the appropriate department.
• Completes social histories and psychosocial assessments, including prior living arrangements, baseline function, support systems, coping skills, cultural preferences, cognition, mood and available community resources.
• Identifies patient goals, preferred discharge location, caregiver availability and potential barriers to discharge at the start of the stay. Verifies appropriate contacts and decision-making representatives through available documentation.
Care Planning and Patient and Family Support
• Participates in interdisciplinary care planning and rehabilitation rounds with nursing, therapy, medical providers and other team members. Updates psychosocial goals and interventions as patient needs change.
• Coordinates and participates in patient and family meetings to discuss progress, care needs, discharge options and unresolved concerns. Encourages patient participation and involvement of supports chosen by the patient.
• Provides supportive counseling, education and referrals within the employee’s role and training for adjustment, grief, anxiety, caregiver stress and changes in health or independence.
• Communicates psychosocial concerns, mood or cognitive changes, behavioral needs and safety concerns to the appropriate team members; seeks supervisory or clinical consultation when needs exceed the role’s scope.
• Assists patients and families with advance care planning conversations and access to advance directive information; refers clinical, legal or specialized questions to appropriate professionals.
• Advocates for patient rights, privacy, dignity and informed choices. Helps resolve concerns and connects patients and families with the appropriate grievance or support resources.
Discharge Planning and Transitions of Care
• Coordinates individualized discharge planning throughout the stay, using the patient’s goals, current function, home environment, available supports and interdisciplinary recommendations.
• Assesses barriers such as limited caregiver support, housing concerns, transportation, finances, service availability and equipment needs. Communicates barriers promptly and works with the team to identify options.
• Collaborates with therapy and nursing to clarify assistance needs, caregiver training and recommended equipment. Confirms the patient’s and caregivers’ understanding of the proposed plan and their ability to arrange needed support.
• Coordinates referrals to home health agencies, community programs and other providers. Works with the team and vendors on durable medical equipment and supplies, and follows up on referral acceptance and anticipated start dates.
• Assists with referrals and applications for assisted living,…