CD Patient Care - Continuing Care - Medical Social Worker (BSW or MSW); Full-time, MMMC

Job Summary

Provides social work services, including psychosocial assessment, discharge planning, care coordination, and resource navigation for patients and their families. Collaborates with the interdisciplinary team to ensure safe transitions of care and addresses psychosocial needs during hospitalization. Serves as liaison between Maui Health System (MHS) and community agencies to integrate services and enhance patient outcomes.

Essential Responsibilities

• Conduct psychosocial assessments to identify patient and family needs related to hospitalization, discharge planning, and community resources.
• Develop and implement social work service plans focused on resource needs, support systems, and care transitions.
• Coordinate discharge planning and care transitions, including referrals to appropriate providers, to ensure safe and timely discharge to home or post-acute care settings.
• Manage socially complex cases involving barriers to discharge such as homelessness, behavioral health concerns, substance use, guardianship, abuse/neglect, or lack of caregiver support.
• Collaborate with community agencies and legal resources to address complex social determinants of health and ensure safe discharge planning.
• Provide crisis intervention and emotional support for patients and families during acute medical events, trauma, or end-of-life situations.
• Facilitate family meetings to clarify goals of care and address psychosocial concerns.
• Perform case management and resource navigation, including financial assistance, insurance benefits, transportation, and community programs.
• Advocate for patient rights and assist with advance directives and healthcare decision-making support.
• Ensure compliance with CMS Conditions of Participation for discharge planning and maintain HIPAA standards for confidentiality.
• Participate in interdisciplinary rounds and care conferences to communicate patient needs and advocate for appropriate services.
• Provide culturally competent care, respecting diversity and incorporating cultural values and family-centered practices.
• Document according to departmental standards and regulatory requirements to assure compliance and continuity of care.
• Participate in performance improvement activities, maintain educational records, and demonstrate competency.
• Attend departmental meetings, in-services, and assist with orientation of new personnel as assigned.