PERSONAL HEALTH PARTNER SOCIAL WORK (PHP-SW)

Transcription

1 MULTICARE HEALTH SYSTEM PERSONAL HEALTH PARTNER SOCIAL WORK (PHP-SW) We are looking for dynamic, creative, innovative and energetic health care professionals. Join our cutting edge team in the new role of Personal Health Partner, offered only at MultiCare. These roles are uniquely suited for the individual who is ready to engage and support patients and families across sites of care (ambulatory and hospital settings) to support them in achieving the best health outcomes. Work closely with our physicians and staff to synchronize our patients care across the continuum. Help us build an exemplary program that supports our patients, families and community in health, illness and recovery. GENERAL DESCRIPTION The Personal Health Partner-Social Work (PHP-SW) is responsible for exemplary cross continuum care coordination, psychosocial assessments, and psychosocial interventions. This individual works with physicians, peers, community colleagues, and others to orchestrate care across the health care continuum, to identify opportunities to continually improve patient care and services, to improve population health, and to achieve collaborative practices that exemplify MultiCare Health System s commitment to patient centered care and community engagement. PRINCIPAL ACCOUNTABILITIES Conduct Ensures that the division mission, vision, and values are actualized Provides exemplary customer service to the patient, family, physician, and care team members Models and orchestrates consistent, professional communications and maintains consistent and proactive communication patterns with colleagues and staff Establishes rapport and relationships with hospital staff and leaders, community physicians, physician practices, and post acute providers Highly visible within MultiCare Health System (MHS) facilities and market Responds positively to change Delegates responsibilities appropriately, but remains accountable for outcomes Patient and Family Ensures that the patient and family experience seamless and safe transitions of care Ensures that patient and family engagement are an integral and essential component of the care delivery process Advocates for patients and families Conducts proactive case finding in addition to responding quickly to case referrals Collaborates with PHP colleagues to coordinate and develop appropriate and safe next level of care arrangements Provides pertinent patient and family education Addresses acute patient and family needs, but ensures that the plan of care incorporates components necessary to promote health and prevent illness over the long term

2 PAGE -2- Ensures that patients and families receive education on health and wellness activities and interventions, next steps, and other critical factors in overall health maintenance and improvement Physicians Partners with and supports physicians in patient care activities and post acute care planning Collaborates with physician(s) to set daily rounding times or meetings based on the physician schedule and what is best for the patient Participates in, and contributes to, daily physician rounding Engages physician partners in psychosocial plan of care Proactively communicate with physicians Community Develops significant market savvy, ensuring that services and interventions address the needs of the market demographic, and are sensitive to cultural and ethnic practices and beliefs Establishes significant functional relationships with community providers and community service agencies, monitoring the integrity of care and services Understands community health challenges and works with the director and division staff and colleagues to develop and implement practices, education programs, and other strategies to improve the health of the community and to promote continuous improvement in health status across the continuum Visits community care providers to develop rapport, understand service offerings, and insure quality and consistency of services Diligently supports and participates in division and market specific strategies Works with post acute care staff to develop community strategies for post acute and community services Care Facilitation and Coordination Performs cross continuum care activities, which may include clinic, physician practice, urgent care, patient home, skilled care, or other sites of care, as appropriate Synchronizes care with all providers and colleagues Adheres to MHS Transitions of Care Standards Collaborates closely with PHP colleagues on all aspects of care delivery Works quickly to address barriers and challenges associated with cross continuum care coordination and engages colleagues and staff in hard wiring appropriate solutions Accountable for accurate and timely documentation Assists and collaborates in the management of patients with chronic diseases following established protocols and interventions Ensures absolute compliance with CMS and other regulatory initiatives Coordinates healthcare interventions for populations with significant health conditions in which self-management efforts are critical Assists with financial counseling and insurance enrollment to facilitate post acute care Knowledge Participates in pertinent, ongoing, relevant education that contributes to professional knowledge and enhances practical abilities. Attends 70% of division educational programs. Attains significant knowledge of Population Based Care, Clinical Integration, and Accountable Care Provides at least two educational programs per year to hospital staff Participates in and supports research activities Serves as a resource for staff, colleagues, and physicians regarding industry trends, regulations, and available programs Maintains proficiency in financial assistance programs such as Medicaid Assessment & Analysis

3 PAGE -3- Accesses and acts on information related to readmissions, throughput activities, denials, and barriers to effective care Stays alert for, and acts upon opportunities for improvement of care and processes Maintains constant awareness of performance and service outcomes, inclusive of financial, operational, process, value, and relational coordination measures Understands and analyzes data related to patient populations/conditions and collaborates with PHP and physician colleagues to improve outcomes. Monitors progress over time and initiates changes as needed Immediately addresses deficits as they are identified Works with colleagues to eliminate avoidable days and denials Collaborates with colleagues to quickly address all potential financial losses identified through denial management processes Participates in clinical cost reduction opportunities Executes cost reduction/containment strategies without adversely impacting patient care within the organization With PHP partners, identifies, studies, and acts upon at least two significant clinical cost reduction activities per year in collaboration with physicians and possibly other clinical partners Collaborates with physicians and colleagues to develop a plan of action to promote appropriate utilization of resources across the continuum Psychosocial Intervention Practices proactive case finding and quick response to referrals Collaborates with the healthcare team in developing and managing the patient's plan of care Provides consultation to physicians and staff regarding the patient s psychological, financial, developmental, family, and other pertinent challenges Coordinates patient/family/physician conferences Provides psychosocial support for complex patient/family needs, which may include situational problems related to death and dying, coping with crisis, and access to resources Works with community agencies to arrange services for patients with chronic or complex care needs, or to encourage general wellness and health Develops and maintains significant knowledge of relevant medical/legal issues impacting patient care, including advanced directives, child abuse, and elder abuse Manages the assessment, referrals, reporting, and care coordination associated with suspected child or elder abuse Coordinates with law enforcement and Children's Protective Services to complete legally mandated reports in situations of suspected child abuse or neglect, child sexual abuse, adult and elder abuse and neglect, and domestic violence Collaborates with outside agencies and patients regarding adoption and newborn surrender Participates in the on call schedule Provides psychosocial intervention addressing any atypical parent or child behaviors Collaborates with PHP colleagues to execute patient placement in hospice, palliative care, behavioral health placement, and homeless shelters Addresses guardianship issues and follows through to ensure appropriate guardianship is assigned Works with patients on Advance Directives (ADs), Durable Power of Attorney (DPOA), and identification of a proxy if needed Assists with completing Do Not Resuscitate (DNR) and Do Not Attempt to Resuscitate (DNAR) paperwork as requested Completes preadmission screening and annual resident review (PASARR) for individuals for skilled care and nursing home placements

4 PAGE -4- Ensures that appropriate resources are identified and scheduled for patients who require continuing psychosocial/mental health interventions or therapy Develops patient self management goals and monitors the progress Facilitates financial assistance to patients and families Collaborates with PHP colleagues to facilitate medication assistance Documents intervention and plan of care in the patient care record in accordance with established departmental and MHS documentation standards MHS Other Contributes to the success of the organization by meeting organizational competency expectations and core values (respect, integrity, stewardship, excellence, collaboration and kindness), continuously learning, and by performing other duties as needed or assigned Adheres to MHS Attendance and Punctuality Policy and Procedure standards. Maintains reliable attendance VALUES BASED BEHAVIORS Respect: Seek first to understand Integrity: Do the right thing Stewardship: Live lean Excellence: Be your best/act for safety s sake Collaboration: Team up Kindness: Create warmth and comfort MIMIMUM QUALIFICATIONS KNOWLEDGE, SKILLS, & ABILITIES Information and Decision Making Demonstrates critical thinking skills, ability to assess, problem solve, and effectively make decisions Learns quickly and is able to mine useful information and data from multiple sources Comfortable taking measured risks Ability to accurately interpret data, critically analyze data and challenge data as appropriate Can quickly focus in on the mission-critical agenda Interpersonal Skills Communicates and works effectively in highly matrixed settings Warm, friendly and interpersonally agile, easy to approach and talk with Behaves consistently with a core set of values, beliefs Strong conflict management and negotiation skills Creative and visionary approach to problem solving Excellent presentation skill Effective Use of Self Excellent time management skills Ability to thrive in a high pressure environment Acts with integrity in adversity Self insight, self development Personal Resources Enthusiastic and high energy, drive, and ambition Understanding of the healthcare industry and business Understanding of the payer industry and business

5 PAGE -5- Writes and presents effectively, and adjusts content for the audience Addresses challenges head on and quickly, through resolution EDUCATION & EXPERIENCE Masters Degree in Social Work Licensed in the state of Washington as a Licensed Advanced Social Worker (LASW), Licensed Independent Clinical Social Worker (LICSW), Licensed Social Worker Associate Advanced (LSWAA), or Social Worker Associate Independent Clinical (LSWAIC); or commitment to obtain within 24 months of hire Five years of recent hospital and/or relevant community/outpatient experience. Note: additional experience, or any experience that is directly relevant (exacting, equivalent) will be considered for determining starting salary Health industry knowledge preferred Healthcare financial assistance knowledge preferred Leadership experience a plus Must have a Washington State driver s license, good driving record and private auto insurance MultiCare believes that each employee makes a significant contribution to our success. Contributions can be within and outside of assigned responsibilities. It is our expectation that each employee will offer his/her services wherever and whenever necessary to ensure the success of our endeavors. Job descriptions represent a general outline of job duties, functions and qualifications. They are not intended to be comprehensive in nature. In addition, jobs evolve over time and therefore their description may not reflect the precise nature of the position at a given point in time. It is MultiCare's policy to base hiring decisions solely on the individual's ability to perform essential job functions. Persons with disabilities are eligible for this position provided they can perform those functions with reasonable accommodation.