Social Worker, Liver Transplant, Full Time, Virtua Our Lady of Lourdes

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Job Summary:

Provides ongoing psychosocial support and navigation services to patients with advanced organ disease, transplant candidates and recipients, mechanical circulatory support candidates and recipients, living donors and caregivers throughout all phases of care. This role spans inpatient and outpatient care settings where the Social Worker collaborates closely with the multidisciplinary care team, ensuring compliance with regulatory documentation standards and is available after hours as needed for emergent evaluations and candidate selection meetings. The Social Worker also provides counseling, crisis interventions, referral to community agencies, education, bio-ethics consultation and complex discharge planning coordination. Works with patients, families and caregivers in a compassionate, culturally competent, age-appropriate manner to facilitate access to transplantation and advanced care services. The Social Worker will participate in multidisciplinary rounds, multidisciplinary selection meetings, as well as outreach initiatives designed to enhance patient and community education about transplantation and advanced care disease services.

Position Responsibilities

Inpatient and Outpatient Psychosocial Assessment and Counseling:

• Uses culturally competent skills to conduct comprehensive psychosocial assessments in both inpatient and outpatient setting addressing patient needs, family dynamics, social histories, and financial needs. Interviews family members and others to obtain relevant information required to develop an individualized care plan based on psychosocial assessment, including age and other factors, throughout all phase of care.
• Communicates pertinent psychosocial data to the transplant and advanced organ disease teams and referral sources.
• Provides supportive counseling in collaboration with patients and families as needed through all phases of care and collaborates and refers to the psychiatry or behavioral health team as needed for additional guidance and support.
• Participate in and develop inpatient and community programs that benefit patients, families, and staff. Implements support groups for specified disease processes or biopsychosocial issues to assist community outreach and development.
• Maintains appropriate and complete documentation of the psychosocial assessment in the inpatient and outpatient setting appropriate interventions, plans, and referrals. Follows up on all referrals from the provider for behavioral health, /psychiatry, substance use disorder treatment, end of life supportive care and other biopsychosocial needs. Make appropriate referrals with respect to patient, family, and transitional needs. Provides education on available resources and strategies for utilizing or gaining access to resources.
• Assist patients with advanced care planning and collaborate with teams to facilitate palliative care or hospice consults as clinically indicated.
• Acts as an advocate for patients and families throughout the continuum of care.

Caseload Management and Care Coordination:

• Maintain a cumulative caseload of patients, providing indefinite support unless a patient relocates or expires. Continually assess and identify the need for emotional support due to illness, financial assistance, medication assistance, lodging and other community resources.
• Manage follow-up for each patient, offering continuous check-ins to monitor psychosocial needs and updating care plans accordingly.
• Prioritize and balance the psychosocial needs of all patients based on the acuity and complex needs of the patients in collaboration with the clinical teams.
• Regularly update the team on patient progress and address any new changes that arise across the care continuum.

Navigation and Coordination of Outpatient and Inpatient Services:

• Primary point of contact for patients and families, coordinating resources across the inpatient and outpatient setting and supporting through the phases of care.
• Participates in multidisciplinary team meetings such as case discussions, discharge rounds and chart review, to formulate discharge plans for patients.
• Collaborate closely with multidisciplinary team members, including physicians, nurses, coordinators, dietitians, pharmacists, financial coordinators in the inpatient and outpatient setting.
• Coordinate follow-up appointments, home health referrals and other outpatient resources to ensure ongoing access to the necessary support.
• Develop comprehensive discharge plans in collaboration with the clinicians, interdisciplinary care team and outcomes managers to ensure they are connected to outpatient and community follow up and resources.
• For outpatients, provide guidance through transplant and mechanical circulatory support evaluations, selection processes, including medication, financial and housing support needed for post procedure recovery.

Education and Support Across the Inpatient and Outpatient Setting:

• Educates patients and families on essential aspects of transplant and advanced organ disease management.
• Provides or assists with in-service education and orientation of new and existing staff.
• Participates in conducting clinical research on important psychosocial aspects of transplantation, living donation and advanced organ disease. Works towards publication and/or presentation of research at local and national social work and transplant related meetings.
• Offers workshops, group sessions, and individual counseling to help patients and care givers to adapt to quality-of-life changes.
• Facilitate support groups to provide a space for shared experiences and coping strategies.

Documentation and Compliance with Regulatory Requirements:

• Document all patients' assessments, encounters, interventions, and care plans in compliance with hospital policies and state and federal governing bodies.
• Ensure all documentation meets the standards set by applicable regulatory bodies.
• Track and report psychosocial indicators as required for compliance, quality assurance and performance improvement.

Position Qualifications Required:

Required Experience:

• Two - three years of experience in healthcare with a focus on transplant, chronic illness or advanced organ disease in the inpatient and outpatient setting.
• Strong understanding of the complex and ongoing needs of transplant and advanced organ disease patients.
• Proficient in care navigation, crisis intervention, discharge planning and managing cumulative caseloads.
• Excellent verbal and written communication skills, problem solving, conflict management, organization, and planning skills.
• Demonstrated competence in providing clinical social work services including psychosocial counseling for supporting patients and families in high stress situations.
• Ability to understand medical terminology, diagnostic criteria, with the ability to communicate effectively with people of diverse backgrounds.

Required Education:

Minimum education of Master's Degree in Social Work (MSW), from an accredited school of social work.

Training / Certification / Licensure:

Current valid New Jersey State Social Worker License. LCSW required.

Valid driver's license may be required.

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