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Medical Social Worker/Discharge Planner

Company: American Advanced Management, Inc
Location: Sebastopol
Posted on: June 10, 2021

Job Description:

Our mission is to provide all of our patients with the highest quality long term acute care and transitional care given in the state of California. We are committed to upholding a culture of shared values that provide dignity, growth, and value to our patients, employees and physicians.

We believe our hospital will provide a variety of quality services that will not only be an asset to the community but a distinct benefit to the surrounding acute hospitals.

It is our vision to become world recognized for our outstanding specialty and long term acute services accomplished through quality, innovation and leadership.

The Long Term Acute Care (LTCH) Division of Sonoma Specialty Hospital is designed to provide care of medically complex patients who have experienced catastrophic illness and/or multi-system failure and are in need of intense rehabilitation services and an extended stay in an acute care setting. These patients usually come directly from a Short Term Acute Care Hospital (STCH) and are in need of vent weaning and acute rehabilitation services for a longer period of time to recover and return to their optimal level of health. The average length of stay (ALOS) of these patients is a range of 25-35 days which is a longer than average stay at a Short Term Acute Care Hospital. Care for these types of patients is provided by RNs, Respiratory Therapists, Wound Care Nurses, Physical Therapists, Occupational Therapists, and Speech Therapists. Also a collaborative team of specialty physicians, psychologists, dieticians, and social workers will focus on an individualized goal for each patient to recover and reach their independence and optimum level of a missing piece in the continuum of care within the health care system.


The Social Worker is responsible for identifying patient and family psychosocial, emotional and cultural needs and priorities for care through assessment, care planning, clinical interventions, education and evaluation of outcomes, adjustment to illness (acute or chronic) and discharge needs. The position will collaborate with Nursing unit, Physician, NP, Pharmacy and other care providers to address the indigent requirements, needs for medications, other resources, and referral processes for entitlements. Through documentation and oral communication, essential information is shared with the health care team members. Works in coordination with LCSW with regard to social services needs of our patient population.

Coordinates policies and procedures, staff education and performance improvement. Maintains performance improvement activities within the department and participates in QPI activities.


  • Collects key psychosocial, emotional and cultural information from patient, family, community agencies and other professional disciplines as part of social work assessment.
  • Demonstrates knowledge of the principles of growth and development over the life span and the skills necessary to provide age appropriate interventions to the patient.
  • Develops a psychosocial and discharge plan, mindful of long term needs, support system, environment, and financial resources.
  • Provides community resource information and referrals for patients and families, including those requiring assistance in meeting health care services/programs/entitlements
  • Provides appropriate counseling and support of patients and family in the acceptance of medical condition, treatment, prognosis and needs after discharge.
  • Facilitate family conferences and/or mediation related to patient care needs, medical condition or treatment. Includes health care and others as determined.
  • Assists physician and other health care professionals in understanding significant social, emotional, and cultural factors related to patient illness or disease process.
  • Assures that social service/discharge planning activities are integrated and coordinated within the hospital system by effective communication at all levels.
  • Develops, implements, and maintains policies and procedures and forms related to Social Services, Discharge Planning,
  • Treats patients and their families with respect and dignity.
  • Communicates appropriately and clearly to Nurse Manager, co-workers and physicians.
  • Maintains a good working relationship both within the department and with other departments.
  • Documentation meets current standards and policies.
  • Manages and operates equipment safely and correctly.
  • Demonstrates an ability to be flexible, organized and function under stressful situations.


  • Five years of active social work services required.
  • Two years of experience as a Medical Social Worker in an acute hospital or LTACH preferred.
  • Clinical experience with geriatric, or terminally ill populations desirable
  • Organization and coordination of resources.
  • Master's Degree in Psychology or Social Work.
  • Current BLS certification preferred.

Keywords: American Advanced Management, Inc, Santa Rosa , Medical Social Worker/Discharge Planner, Other , Sebastopol, California

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