Master Social Worker - MSW

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 FMCNA 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 FMCNA Quality Goals.

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 patients 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 ind