| Receives the intake referral information and prepares paperwork/tools necessary. Obtains all pertinent medical history from patient, family or significant others. Performs the socio-psychological evaluation of the support systems available to the patient and documents necessary emergency contacts etc. Participates in the development of the plan of care and discharge planning. Assists patients and their families with personal and environmental difficulties which predispose then toward illness or interfere with obtaining maximum benefits from medical care (counseling members of the family to assisting patients with admission to a nursing home). Performs the skilled visit and documents accordingly. Provides supportive casework designed to restore patient’s to their optimum level of social adjustment. This includes assisting patients and their families to understand, accept and follow medical recommendations. Assists patients in utilizing the resources of their families and the community at large. Resource utilization may include referring the patients to community resources or acting as an intermediary on behalf of the patients with other health and welfare agencies. Effectively communicates with patient and family. Keeps the patient informed ongoing. Effectively communicates with other disciplines in the case (case conferencing) to effectively and appropriately problem solve as situations arise. Communicates effectively with the Nursing Supervisor scheduled visits planned and changes to the schedule on a weekly basis. Caseload is self-scheduled but communication of the clinician’s schedule is essential. Communication with the patient’s physician (verbally and/or in writing) to obtain effective treatment modalities to effect the best means to obtain the desired outcome. Communicates in the case conferencing sessions to establish best practices for the individual patient’s needs. |