Master Social Worker - MSW

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PURPOSE

AND

SCOPE : Provides

psychosocial services to patients treated by the facility including

in-center and home dialysis patients (if applicable) utilizing

Social Work Theory of Human Behavior and accepted methods of social

work practice. Works with the health care team to promote positive

adjustment, rehabilitation and improved quality of life for our

patients. In collaboration with the interdisciplinary team,

informs, educates and supports staff in understanding the

emotional, psychological and behavioral impact of Chronic Kidney

Disease on the patient and family to ensure comprehensive quality

care of our patients. Supports the Fresenius Kidney Care (FKC)

commitment to the Quality Indicators and Outcomes and Quality

Assessment and Improvement (QAI) Activities, including those

related to patient satisfaction and quality of life and actively

participates in process improvement activities that enhance the

likelihood that patients will achieve the FKC Quality Goals. This

is an entry level MSW

role.

PRINCIPAL

DUTIES AND

RESPONSIBILITIES : Patient

Assessment / Care Planning /

Counseling

As a member

of the interdisciplinary team, assesses patients' psychosocial

status, strengths and areas of need that may affect rehabilitation

and optimal treatment outcomes as part of the comprehensive patient

assessment.

Participates in care

planning in collaboration with the patient and healthcare team to

identify effective interventions that will help the patient meet

rehabilitation, treatment goals, and improve quality of

life.

Utilizes FKC

patient education programs, established social work theory and

methods, social work focused interventions, and quality of life

measurement instruments as part of assessment and care planning to

address barriers and meet patient treatment

goals.

Provides monitoring and

interventions for the patient to adjust to dialysis and achieve

optimal psychosocial status and quality of

life.

Provides supportive counseling services

to patients as permitted within the scope of their clinical

training and state

license.

Provides educational and

goal directed counseling to patients who are seeking

transplant.

Provides

information and assists the team and patient with referral to

community resources (home health services, vocational

rehabilitation, etc.) to facilitate optimal treatment

outcomes.

Maintains

current knowledge regarding local vocational / educational

rehabilitation programs and assist patients with referral and

access to vocational rehabilitation to enable them to remain

employed, become employed or receive education.

Assesses patient

awareness of advance directives; assists with accessing advance

directive forms / information and facilitates discussion of advance

directive wishes, if necessary, with the healthcare team and the

patient's family / support

persons.

In

collaboration with the physician and nurse, participates in the

discussion of patient DNR status in the facility to ensure patient

and / or family understand and make an informed decision about their

care.

Knowledgeable of

and adheres to FMCNA Social Work Policy and Measuring Patient

Physical and Mental Function Policy, including

documentation.

Documents

based on MSW interaction and interventions provided to patient

and / or family.

Quality

Provides

psychosocial support and / or Social Work Focused Interventions to

address non-adherence, quality outcome, and quality of life

concerns for all patients based on acuity

level.

Participates in

monthly Quality review meetings with the interdisciplinary team.

Reports on quality indicators related to adherence, such as Missed

and Shortened Treatments, Quality of Life Trends, and Service

Recovery.

Patient

Education

Assesses

patient knowledge of kidney disease for barriers that may affect

adherence to treatment. Works with patient, family and health care

team to provide education tailored to the patient’s learning style,

communication barriers, and

needs.

With other

members of the interdisciplinary team, provides appropriate

information about all treatment

modalities.

Facilitates

the transplant referral process and collaborates with

interdisciplinary team on transplant waitlist

management.

Provides

ongoing education to patient / family regarding psychosocial issues

related to End Stage Renal Disease (ESRD) and all support services

that are available.

Reviews patient

rights and responsibilities, grievance information (company and

network) and other facilities policies with patient and / or the

patients’ representative to ensure patients’ understanding of the

rights and expectations of

them.

Collaborates

with the team on appropriate QAI

activities.

Patient

Admission and Continuity of

Care

Reviews Patient

Rights and Responsibilities, Grievance Procedure & Important

Numbers Handout, FKC Non-discrimination policy, DNR Statement (if

applicable) and address any immediate

needs / concerns.

Understands

the referral and admission process and supports the clinic in

regard to the patient needs for scheduling to maximize adherence

and adjustment.

The Social Worker

will interview the patient to identify root causes or concerns for

the discharge request, (i.e. transfer to hospice, relocation,

dissatisfaction with services or staff) and share causes / concerns

with operational

leadership.

Insurance

and Financial

Assistance

Collaborates

and functions as a liaison for patient with Insurance Coordinators

to address issues related to insurance.

In collaboration with

Insurance Coordinators, provides information and education to

patients about payment to dialysis (federal, state, commercial

insurance, state renal programs, AKF HIPP, and entitlement

programs).

Collaborates

with the Insurance Coordinator of any changes to patient state that

impacts insurance i.e. transplantation, discharged, loss of

coverage, or extended

travel.

Refers

patients to patient billing solutions (PBS) department for

questions / concerns in regard to treatment related

bills

Staff

Related

Assists with

interview process and decision to hire new personnel if requested

by SW Manager / Senior Manager.

Works with the

administrative support staff to maintain updated patient resource

lists (e.g. maintain updated list of transportation resources).

Provides training to

staff pertaining to psychosocial topics as needed.

Contributes and

participates with weekly team huddles. Discusses any urgent patient

issues with staff.

Adheres

to work defined caseload guidelines based on state regulatory

requirements.

Performs

other related duties as

assigned.

PHYSICAL

DEMANDS AND WORKING

CONDITIONS : The

physical demands and work environment characteristics described

here are representative of those an employee encounters while

performing the essential functions of this job. Reasonable

accommodations may be made to enable individuals with disabilities

to perform the essential functions.

Travel

required (if multiple facilities or home visits, if

applicable)

SUPERVISION :

None

EDUCATION

AND REQUIRED

CREDENTIALS : Masters

in Social Work

Must

have state required

license

Meets the

applicable scope of practice board and licensure requirements in

effect in the State in which they are

employed

EXPERIENCE

AND SKILLS : – 2 years’ related

experience

EOE,

disability / veterans