Fresenius Medical Care
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, assess patients' psychosocial status, strengths and areas of need that may affect rehabilitation and optimal treatment outcomes as part of the comprehensive patient assessment.
Participate 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.
Utilize FKC patient education programs, established social work theory and methods, social work focused interventions, and quality of life measurement instruments to address barriers and meet patient treatment goals.
Provide monitoring and interventions for the patient to adjust to dialysis and achieve optimal psychosocial status and quality of life.
Provide supportive counseling services to patients as permitted within the scope of their clinical training and state license.
Provide educational and goal directed counseling to patients who are seeking transplant.
Provide information and assist the team and patient with referral to community resources (home health services, vocational rehabilitation, etc.) to facilitate optimal treatment outcomes.
Maintain 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.
Assist in advance directive discussions and facilitate access to forms/information.
Collaborate with the physician and nurse on patient DNR status discussions.
Adhere to FMCNA Social Work Policy and Measuring Patient Physical and Mental Function Policy.
Document interactions and interventions provided to patient and/or family.
Quality
Provide 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.
Participate in monthly Quality review meetings and report on quality indicators related to adherence, such as Missed and Shortened Treatments, Quality of Life Trends, and Service Recovery.
Patient Education
Assess patient knowledge of kidney disease for barriers that may affect adherence to treatment.
Provide education tailored to patient learning style, communication barriers, and needs.
Collaborate with interdisciplinary team on transplant referral process and waitlist management.
Provide ongoing education regarding psychosocial issues related to ESRD and available support services.
Review patient rights and responsibilities, grievance information, and other facility policies.
Collaborate on appropriate QAI activities.
Patient Admission and Continuity of Care
Review Patient Rights, Grievance Procedure & Important Numbers Handout, FKC Non-discrimination policy, DNR Statement and address immediate needs/concerns.
Support referral and admission process to maximize adherence and adjustment.
Interview patient for discharge reasons and communicate concerns to leadership.
Insurance and Financial Assistance
Collaborate and serve as liaison with Insurance Coordinators to address issues related to insurance.
Provide information on payment for dialysis (federal, state, commercial, state renal programs, AKF HIPP, entitlement programs).
Collaborate on insurance changes impacting patient status such as transplantation or coverage loss.
Refer patients to patient billing solutions department for billing questions.
Staff Related
Assist with interview process and decisions to hire new personnel.
Maintain updated patient resource lists with administrative staff.
Provide staff training on psychosocial topics.
Participate in weekly team huddles.
Adhere to caseload guidelines based on state regulatory requirements.
Perform other related duties as assigned.
Physical Demands and Working Conditions
Travel may be required (multiple facilities or home visits).
Supervision None.
Education and Required Credentials
Master’s in Social Work.
State required license.
Meet scope of practice board and licensure requirements for the state of employment.
Experience and Skills
0–2 years of related experience.
Equal Opportunity Employer EOE, disability/veterans.
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Principal Duties and Responsibilities
Patient Assessment / Care Planning / Counseling
As a member of the interdisciplinary team, assess patients' psychosocial status, strengths and areas of need that may affect rehabilitation and optimal treatment outcomes as part of the comprehensive patient assessment.
Participate 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.
Utilize FKC patient education programs, established social work theory and methods, social work focused interventions, and quality of life measurement instruments to address barriers and meet patient treatment goals.
Provide monitoring and interventions for the patient to adjust to dialysis and achieve optimal psychosocial status and quality of life.
Provide supportive counseling services to patients as permitted within the scope of their clinical training and state license.
Provide educational and goal directed counseling to patients who are seeking transplant.
Provide information and assist the team and patient with referral to community resources (home health services, vocational rehabilitation, etc.) to facilitate optimal treatment outcomes.
Maintain 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.
Assist in advance directive discussions and facilitate access to forms/information.
Collaborate with the physician and nurse on patient DNR status discussions.
Adhere to FMCNA Social Work Policy and Measuring Patient Physical and Mental Function Policy.
Document interactions and interventions provided to patient and/or family.
Quality
Provide 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.
Participate in monthly Quality review meetings and report on quality indicators related to adherence, such as Missed and Shortened Treatments, Quality of Life Trends, and Service Recovery.
Patient Education
Assess patient knowledge of kidney disease for barriers that may affect adherence to treatment.
Provide education tailored to patient learning style, communication barriers, and needs.
Collaborate with interdisciplinary team on transplant referral process and waitlist management.
Provide ongoing education regarding psychosocial issues related to ESRD and available support services.
Review patient rights and responsibilities, grievance information, and other facility policies.
Collaborate on appropriate QAI activities.
Patient Admission and Continuity of Care
Review Patient Rights, Grievance Procedure & Important Numbers Handout, FKC Non-discrimination policy, DNR Statement and address immediate needs/concerns.
Support referral and admission process to maximize adherence and adjustment.
Interview patient for discharge reasons and communicate concerns to leadership.
Insurance and Financial Assistance
Collaborate and serve as liaison with Insurance Coordinators to address issues related to insurance.
Provide information on payment for dialysis (federal, state, commercial, state renal programs, AKF HIPP, entitlement programs).
Collaborate on insurance changes impacting patient status such as transplantation or coverage loss.
Refer patients to patient billing solutions department for billing questions.
Staff Related
Assist with interview process and decisions to hire new personnel.
Maintain updated patient resource lists with administrative staff.
Provide staff training on psychosocial topics.
Participate in weekly team huddles.
Adhere to caseload guidelines based on state regulatory requirements.
Perform other related duties as assigned.
Physical Demands and Working Conditions
Travel may be required (multiple facilities or home visits).
Supervision None.
Education and Required Credentials
Master’s in Social Work.
State required license.
Meet scope of practice board and licensure requirements for the state of employment.
Experience and Skills
0–2 years of related experience.
Equal Opportunity Employer EOE, disability/veterans.
#J-18808-Ljbffr