CARE MANAGER- Social Worker / Complex Care

DEPARTMENT: Social Services



PURPOSE OF POSITION: To demonstrate advanced level clinical practice skills in providing psychosocial assessment and intervention services to patient and families. To facilitate and manage care coordination and provide care coordination services and partner with additive case management services across the continuum of care for CCHMC patients. Working within a collaborative framework, insures the effective and efficient coordination and management of care to all patients within his/her caseload. This individual works to ensure that patients move along the health care continuum, promoting quality care, through appropriate, cost-effective interventions while maintaining close contact with patients, families, care providers, payers, and community resources.

·Compliance - Patient Services Staff
Sustain a working understanding of regulatory requirements and accreditation standards. Support leadership in Compliance efforts to meet and sustain the regulatory compliance efforts of the department and hospital. Be mindful and judicious in monitoring safety and departmental policies and procedures. Ensure all individual certifications and Safety College requirements are fulfilled in a timely basis. Work with department managers, nurse council and magnet representatives to identify and share safety best practices. Be mindful of CCHMCs processes and compliance with CMS standards and freely communicate safety and compliance concerns to leadership team members.
·Psychosocial Assessment
Conduct a comprehensive psychosocial assessment of the patient's/family's health and psychosocial needs while exercising an intuitive understanding of complexity and uniqueness to identify strengths, challenges, and opportunities. Identify cases that meet criteria for need of care coordination through the comprehensive needs assessment. Stratifies patients to match client needs to the most cost effective model of care coordination. Meets each new patient within the caseload, introduces self and explains the Care Manager Role. Exhibits advanced interviewing and therapeutic intervention skills with regard to abuse, neglect, and/or other safety risk factors. Facilitates collaboration with community agencies to enhance investigation and intervention process.
·Psychosocial Intervention
Provide psychosocial services as identified in the patient's comprehensive plan of care. Creates opportunities for and provides supportive counseling with the goal of maximizing emotional coping and adherence to the treatment plan. Facilitates and enhances collaboration with the referral source and appropriate members of the health care team in a timely and effective manner. Use expert knowledge and skill to educate the patient/family/caregiver and members of the health care team about evidenced-based treatment options. an expert in providing self-management support to high risk/complex patients/families to increase their skills and confidence to effectively manage their chronic care conditions at home. Identifies needs, develops programs, and evaluates outcomes for special populations as needed, and implements changes based on outcomes. Motivates and empowers patients/families/caregiver through the use of anticipatory guidance and planning to reduce or eliminate psychosocial barriers to discharge. Is seen as a leader in initiating and facilitating family centered care team meetings. Demonstrates a therapeutic approach focusing on micro and macro systems including assessment and crisis intervention with the goal of problem prevention.
·Interdisciplinary Collaboration
Working for system improvement, promoting patient/family/caregiver well-being. Advocates for patient population on a system level (hospital, organization, and/or community) by developing programs and protocols to better meet the needs of the patient population. Is seen as a resource and initiates liaison role between the patient/family/caregiver within the medical team and outside agencies. An expert in mediating as needed within the medical team on behalf of the patient/family/caregiver. Empower the patient/family/caregiver to problem-solve by exploring options of care when available and alternative plans, when necessary, to achieve desired outcomes. Develops processes for effective and efficient communication and coordination between members of the health care team while involving the patient/family/caregiver in the decision making process in order to minimize fragmentation of services.
Planning with the patient, family or caregiver, the primary care to achieve quality and cost effective outcomes. Provides self-management support to high risk/complex patients and families. Utilizes collaborative communication skills to establish a working partnership with the patient/family, treatment team, and community resources/providers. Educates the client, the family or care-giver and members of the health care delivery team about treatment options. Integrates patient/family decisions and choice into the planning process. Coordinates the plan of care and maintains documentation of case updates and discussion/events involving individuals responsible for patient welfare (e.g. family, providers, and care team members). Identifies the need for patient/family team meeting, participates in the meeting and documents the outcomes. Proactively identifies hospital clinical services needed by the patient. Reassess plan of care and adjusts plan according to patient needs. Support and facilitate all care transitions from inpatient to outpatient, practice to practice and from pediatric to adult systems of care.
Facilitates communication and coordination between members of the health care team (including the medical home and community services), involving the patient/family in the decision-making process in order to minimize fragmentation in the services. Attends and leads care conferences. Insures that key components of the plan of care and/or patient needs are communicated to subsequent care providers and ensure safe handoffs. Ensures the health care team integrates multiple sources of health care information and communicates this summary, thereby building caregiver skills and fostering relationships between the health care team and families. Demonstrates an understanding of legal and regulatory issues (HIPPA, EMTALA, regulatory agencies, CMS, legal P&P) impacting the care delivery and reimbursement process. Negotiates and advocates for the patient for services and resources needed. Provides patient/family education regarding post-acute services, community resources or other as needs identified. Creates an environment to support patient safety by integrating patient safety goals into daily practice based of the patient's age and the population served.
·Resource Management
Partner with the patient/family/caregivers in obtaining financial assistance, community resources, and/or specialized equipment. Develops resource networks, excels at resource utilization, and acts as a resource to peers. Provide real time accurate information to patient/family/caregiver for resources for which they are eligible. Provide condition-specific and related medical, financial, educational, and social supportive resource information.
·Monitoring/Evaluation Outcomes
Continual assessment/reassess patient/family to ensure progress towards goal and interventions on the plan of care, and/or identify new needs. Evaluate the timeliness and availability of treatments and services, and adjusting level of service according to changing needs. Monitor the patient's progress in achieving the goals, objectives, and expected outcomes of the plan at specified time frames. Identifies documents and communicates barriers to the plan of care to the healthcare team. Serves as the contact person for and works collaboratively with nursing to manage resource usage. Evaluate actual patient outcomes in relation to expected outcomes. Identifies quality improvement opportunities and consistent issues and communicates them to the unit's management team, providing supporting data when possible. Participates in the management of metrics (outcomes, value, and experience) for the population across the continuum of care.
Serves as a team leader and expert resource on biopsychosocial issues impacting the care of patients/families. Leads in outcomes based practice. Leads in the development of processes and system to measure/monitor practice. Guides healthcare team in delivery of appropriate healthcare services. Collaborate with appropriate parties to plan, implement, and/or evaluate services. Assumes accountability for facilitating psychosocial aspects of patient's plan of care. Contributes to an overall team effort and accomplishment of goals. Serves as a resource for other members of the health care team. Participates in departmental education. Identifies own practice abilities and limitations and obtains instruction and supervision as necessary. This includes seeking education for self-development. Demonstrates adherence to the Code of Ethics for profession and according to system policy. Demonstrates ability to hold self and other providers accountable. Understands, applies and supports departmental/hospital policies, procedures and standards. Monitors email, phone messages and responds in a timely manner.

Skills & Competencies
·Professional Knowledge
Professional knowledge and clinical ability to provide psychosocial services to pediatric patients and families
Excellent verbal, written and interpersonal communication skills
Understanding and showing respect and appreciation for the uniqueness of all individuals; leveraging differences in others' perspectives and ideas; appreciating cultural differences and adjusting one's approach to successfully integrate with others who are different from oneself
Demonstrate an independent work initiative, sound judgment, problem solving skills, leadership ability, diplomacy, tact and professional demeanor
·Business Acumen
Possesses skills of system thinking, directing others and organizational agility

·Master in Social Work
·Current license to practice in the state
·Licensed Independent Social Worker (LISW) within 2 years of hire
·5 years of professional experience

·Certification in Case Management
·LISW Preferred