Social Worker, Care Coordinator LSW/MSW, Trauma - Full-Time

• Assesses all patients who are admitted for medical care to the trauma service, screened for potential discharge needs regardless of race, age, sex, religion, diagnosis and ability to pay. Meets directly with patient/family to assess needs and develop an individualized plan in collaboration with the physician and other members of the health care team.
• Facilitates communication and coordination between members of the health care team and involves the patient/family in the decision-making process, in order to minimize fragmentation of services, manage resources and remove barriers to the plan of care. Provides social work intervention to patients and families to assist their ability to cope with traumatic injury and stress.
• Maintains current and up to date information of community resources and refers patients to those community resources which will enhance patient's life. Consults with other community agencies and committees to identify potential resources to support patients and their families.
• Works collaboratively with all team members of the multi-disciplinary health care team and external to effect timely and appropriate transitions to the next appropriate level of care. Involved in crisis intervention and support activities. Responds to trauma codes to assist in the patient and family¿s support. Assists in gathering and proper notifications of family and community resources.
• Develops a discharge plan, in collaboration with the patient/family patient caregiver, patient support persons and healthcare team that will provide maximum benefit for each patient. Ensures that the discharge plan will be the least restrictive environment that best meets the continuing care needs of the patient. Ensures provisions of continued care at home or in an appropriate extended care facility based upon the patient needs. Confirms the patient has a primary care provider upon discharge or refers appropriately to an ACO or FQHC.
• Documents and communicates information to the Multidisciplinary Team in order to coordinate and maximize care. The EMR reflects the education, coordination of home care services, and placement in an extended care facility, durable medical equipment, and referral to complex care management team, ACO navigators and authorizations from providers.
• Participates actively on appropriate committee (i.e. Trauma DSC committee), workgroup, and/or meetings. Is responsible for trauma DSC and ACS social services related metrics (i.e.: CAGE screening, smoking cessation, PTSD counseling, and referrals, etc.). Is a positive problem solver. Identifies and refers quality issues for review to the Quality Management Program.
• Participates in Multidisciplinary Team Rounds, specific to trauma. Brings forth issues which impact on discharge as well as LOS to the team, in a timely manner, for discussion and resolution.
• Reassesses periodically and evaluates against care goals and the plan of care and, when indicated, the plan or goals are revised. Medical records reflect that each patient¿s discharge plan is re-assessed no less than weekly in response to change in medical situation.
• Provides patients and families with resources and discharge options. Educations about risks and benefits of discharge options. Educates patients on how to obtain services and available heath care benefits. Patients are educated regarding their health status. Second Important message is provided to Medicare patients 24 to 48 hours prior to discharge.
• Participates in research as it relates to trauma and utilizes pertinent research for managing patient care issues. Provides in-services to the trauma service and other departments as requested. Demonstrates current knowledge of trauma care through the life span via literature, trauma rounds and conferences. Regularly attends and participates in Trauma Conferences, team rounds, multidisciplinary rounds, Trauma Committee, and other conferences/meetings as appropriate.
• Responsible for facilitating weekly inpatient family support sessions and responsible for referring patients for outpatient trauma support groups for post-discharge needs.
• Collaborates with all members of the multidisciplinary team to support the following functions: crisis intervention, counseling support and referrals, abuse/neglect, guardianship, and psychosocial assessment.
• Referrals should be made to the following as required/needed:

• Acute Rehabilitation Facilities
• Sub-Acute Facilities
• Long-term Care Facilities
• Assisted Living Facilities
• Adult Day Program
• Level 1 / Level 2 PAS/PASSAR
• EARC PAS
• Home Care
• Hospice at Home/Facility
• DME Equipment
• Ambulance Transportation
• Renal Dialysis Slots
• Financial Assessment
• North Hudson Clinics
• Medication Indigent Programs
• Community Linkage
• End of Life Issues
• Boarding Home Placement
• Mental Health Services
• Homeless Placement
• Medicaid
• Division of Child Protection and Permanency (DCP&P)
• Collaborate with Utilization Review Nurses
• Completes all other necessary duties as assigned by the trauma service with attention to detail and inca timely manner.
• Other duties as assigned.

• Master's of Social Work
• Two years of experience as a social worker in a health care setting.
• Trauma Certification in Social Work required within 1 year from date of hire.

• NJ Licensed Social Worker.

• NJ Licensed Clinical Social Worker.
• Certified Case Manager or Accredited Case Manager Certification.
• Trauma Certification in Social Work.

• Regular contact with Medical Center personnel, patients and visitors.

Hackensack Meridian Health