Saint Joseph Hospital is a 433-bed facility located in Lexington Kentucky. Founded in 1877 a small group of Sisters of Charity of Nazareth in Kentucky led by Sister Euphrasia Stafford began their health ministry. Their mission was to provide compassionate care to the poor and underserved – a tradition still carried out today. Saint Joseph Hospital primarily serves central and eastern Kentucky with a full range of services including distinguished awards for cardiology orthopedics and stroke care. CHI Saint Joseph Health supports 5000 active employees 8 hospitals specialty clinics and a Medical Group with more than 200 locations across Central and Eastern KY. CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health in 2019. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.

Job Summary / Purpose

The Social Worker is responsible for performing social work assessments and interventions as needed while working with the Community Paramedicine team for post hospitalized patients and emergency department patients. The functions of the Social Worker include: crisis intervention, patient/family intervention, high-risk screening, brief counseling, referrals for financial or other identified resource needs, arrange and facilitate family/patient representative meetings with the health care team as needed, arrange post-acute placement on complex discharges and engagement of appropriate agencies or community resources when high-risk patients are identified. 

Essential Key Job Responsibilities

Social workers are responsible for:

1. Collaborate with multidisciplinary teams and patients to evaluate and assess patients’ medical and physical needs. 
2. Identify social determinants affecting patients (individual, community, transportation economics, environment, social support, etc).
3. Identify special needs variables, cultural variables and mental health variables affecting patient care (language, religion, ethnicity, race, physical disability, dementia, age, cognitive disorders, substance disorders, psychotic disorders, anxiety, depression, autism, abuse, neglect, malnutrition, PTSD, medical literacy, etc).
4. Participate in plan-of-care as determined to meet individual patient needs; determine need for community resources (mental health, substance abuse, public health, etc); provide referrals for community resources.

1. Providing developmentally appropriate care for all populations served: plan for the continuity of care, recognize and plan for the unique needs of all ages, the physically disabled, mentally ill, chronically ill, terminally ill, vulnerable patients, etc. 
2. Advocacy and education: patient/family self-care management; patient/family health management education; bioethics referrals and management; physician, staff, and community education; case/care management/coordination education and training; risk management identification and referral.
3. Psychosocial management: crisis intervention; psychosocial assessment/functioning; counseling support and referral; abuse/neglect/trafficking identification, assessment, and referral (partner, child, elder, etc.); family issues affecting care; coping/emotional adjustment; grief/bereavement support (individual and group); adoption, surrogacy, and safe surrender support, management, and resources; health/wellness promotion; substance abuse screening, management, and resources; psychiatric screening, management, and resources; staff support; assessing, addressing, managing, and resources related to social determinants of health (e.g. housing and food insecurity, transportation).
4. Patient/Family Care Conferences: interdisciplinary care communication/coordination related to continuity/transitions of care planning and management.
5. Continuity/Transition Management: As part of Care Management/Coordination team, facilitation of patient decisions and communications regarding post-acute care; professional responsibility for knowledge of community resources related to clinical social work scope of service and functions and social worker discretion; maintaining appropriate up-to-date resource lists; education for patients/families about availability of community resources; mental health service and support coordination; grave disability, palliative care/end-of-life, and hospice patient/family support, referrals, and management; interventions, management, and coordination of transition planning for psychosocially complex cases.
6. Utilize consultation data and social work experience to plan and coordinate client or patient care and rehabilitation, following through to ensure service efficacy.
7. Community Resource Coordination: life-care planning; expert consultation on health care resource management; team and patient education regarding various health-related insurance/support programs (e.g. CCS/Medicare/Medicaid/SSI); building and maintaining community relationships to address needs of patients experiencing homelessness and to meet other social determinants of health needs.
8. Performance & Outcomes Management: in-depth understanding and application of federal/state/local regulatory agency guidelines, The Joint Commission standards, and other regulatory and accreditation requirements; implement evidence-based practices; support organizational financial performance, length of stay, cost per case, readmission prevention efforts and revenue cycle goals. 
9. Participates in performance improvement teams and programs as necessary.
10. Demonstrates behavior that aligns with the mission and core values of the organization. 
11. Responsible for completing required education within established timeframes.
12. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice.
13. Performs other duties as assigned.

Minimum Qualifications