Social Worker - MSW

Trinity Health MI; Chelsea (MI); On-site; USD 30,307 - 46,838; Part time

Job summary

Trinity Health MI is seeking a Part-time Social Worker to provide psychosocial assessment, counseling, and discharge planning for patients and families in a Michigan setting. You will collaborate with an interdisciplinary team, coordinate transitions of care, and connect patients with community resources to support ongoing recovery.

The role emphasizes culturally sensitive care, advocacy, and ongoing evaluation of patient needs within a care continuum.

Qualifications

• Master of Social Work degree from an accredited program.
• Current Michigan social work license.
• Strong communication and counseling skills.

Responsibilities

• Function as part of an interdisciplinary care management team.
• Interview patients and families; develop psychosocial assessments and intervention plans.
• Provide direct psychosocial services and crisis intervention to patients and families.
• Coordinate discharge planning and transitions of care across care settings.
• Refer to community resources for financial, counseling, and mental health support.
• Document assessments and progress notes; monitor outcomes and quality improvement.

Skills

Interpersonal skills

Analytical skills

Mobility to move between units

Leadership and team collaboration

Education

Master's Degree in Social Work

Michigan Social Work License

Job description

Position Purpose

Assists patients and families in coping with problems associated with severe and long‑term illnesses. Conducts patient and family interviews, prepares psychosocial assessments, develops treatment plans, provides counseling and crisis intervention, and directs patients to designated community agencies and resources.

Responsible for coordinating the health care plan (including discharge plans from the acute setting and transitions of care to the post‑acute care network) for assigned patient populations through the use of care plans, critical pathways, managed care and collaboration with all members of the health care team. Evaluates care based upon quality, access, and cost‑effectiveness.

Maintains the continuum of care through the coordination and integration of all phases of patient care. Provides consultation to patient treatment team members and participates in developing new patient care programs. In various SJMH settings, may provide individual, family, and/or group treatment as part of an interdisciplinary treatment plan.

Provides quality patient care considering age‑specific, developmental, cultural, spiritual, diversity, and/or other special needs or circumstances through competent clinical practices.

Employment Type: Part time

Shift: Day Shift

Essential Functions and Responsibilities

• Functions as a member of the interdisciplinary care management team.
• Interviews patients and families to obtain psychosocial data; evaluates and gathers data from the patient, family, outpatient supports, and other collateral sources (including the primary care provider) regarding the plan of treatment and available resources and develops an appropriate intervention plan.
• Provides a variety of direct services and clinical interventions to provide continuity of care and help patients and families resolve socio‑emotional problems associated with adjustment to illness, resource needs, mental health problems and a variety of life events and transitions.
• Coordinates care of identified high‑risk patient population across the continuum, addressing psychosocial issues. Collaborates with patient, family and primary care provider to develop a plan to address and manage issues which influence health care utilization including services for home, and facilitates hospital‑to‑hospital transfers, hospice, extended care facility, acute rehabilitation and long‑term care facility placement.
• Refers patients to designated community agencies or resources for financial assistance, counseling, mental health and substance abuse follow‑up, and other support services.
• Conducts continuity of care planning for assessing needs and support services for home, and facilitates hospital to hospital transfers, hospice, extended care facility, acute rehabilitation and long‑term care facility placement.
• Accountability for discharge planning/continuing care needs for assigned populations. Assesses, develops, and implements continuing care plans based on identification of patient’s health self‑care, knowledge, and/or social support system deficits. Conducts ongoing assessment and interdisciplinary collaboration regarding continuing care needs through the continuum. Applies expertise regarding Service Provider Criteria, Insurance Coverage criteria and identification of patient needs. Collaborates with interdisciplinary team regarding patient progress towards expected outcome and revisions to plan of care. Initiates referrals to other providers and disciplines (i.e., Infectious Diseases, Risk Management) as indicated. Refers to Skilled Home Care, Durable Medical Equipment vendors and other appropriate referral sources to assist patient in achieving a safe, optimal continuing care plan. Collaborates with patient/family to ensure appropriate continuity of care arrangements and agency/vendor.
• Provides ongoing assessment of educational needs of patient/family in collaboration with interdisciplinary staff and develops appropriate interventions and programs in response and maintains good working relationships with community resources. Demonstrates ability to make appropriate and useful changes in the patient’s treatment plan when problems persist and recognizes when discharge and/or transfer of care is in the best interest of the patient.
• Advocates, educates, and facilitates resolution of patient rights, ethical and legal issues such as advance directives, end‑of‑life decisions, guardianship, etc.
• Systematically identifies and addresses barriers and fragmentation of care while proactively/collaboratively problem‑solving to find solutions.
• Documents social work assessment data and progress notes for each patient including nature of psycho‑social concerns, patient and family supports and needs, and intervention plan in accordance with department documentation standards.
• Provides consultation to other patient treatment team members regarding socio‑emotional factors that affect patient’s condition, treatment plan and recovery.
• Regularly communicates with other departmental and community agency personnel to coordinate social work functions and other services, exchange patient information, and ensure continuity of care.
• Utilizes pertinent population data to identify trends, potential areas of targeted intervention. Uses metrics to establish measurable goals and monitor outcomes. Uses professional expertise to advance policies and practices that improve access to care, ensure timely follow‑up care and supports the delivery of evidence‑based clinical management.
• In conjunction with identified leadership, develops, implements and monitors clinical (and non‑clinical) quality improvement processes. Regularly prepares and presents written reports that track, monitor and measure outcomes of interventions to address patient/population needs and identify and remove barriers.
• Provides Social Worker leadership in related committees, task forces and work groups with a focus on improved health outcomes for the populations served. Serves as a change‑agent and resource to foster adoption of process/service/system improvement initiatives at various points of services. Serves as an advisory role for social policies in community development programs.
• Understands legal issues that affect treatment, including but not limited to child custody, divorce laws, child/adult abuse, duty to warn, recipient rights policies and procedures, alternative treatment orders (ATO’s), and the commitment of inpatient hospitalization.
• Maintains knowledge of current trends and developments in the field.
• Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of co‑workers, and to report all preventable hazards and unsafe practices immediately to management. Reports all preventable hazards and unsafe practices including near misses and actual errors either to management or using the SJMHS anonymous reporting system (VOICE).
• Attends and participates in departmental, Health System, and community committees and meetings as necessary.
• When working on the Complex Social Work; provides care coordination, education, transition management, and outreach services to high‑risk or high‑utilizer patients in the post‑acute care space.
• When working on the Complex Social Work; acts as liaison between inpatient and outpatient care settings to ensure continuity of care throughout each site of care, and to ensure communication about and adherence to the established plan of care for each patient.

Required Education, Experience, and Certification/Licensure

Knowledge of social work as normally acquired through completion of a Master's Degree in Social Work from an accredited college or university or equivalent knowledge. Must have current social work license in the State of Michigan.

Required Skills and Abilities

Interpersonal skills necessary to obtain information, provide counseling and interact effectively with patients and families and SJMHS colleagues. Analytic skills necessary to assess patients’ needs, develop associated discharge planning and provide sound advice and guidance. Ability to concentrate and pay close attention to detail for up to 90% of work. Must be mobile enough to move between nursing units and outpatient settings and in/out of patient rooms and offices. Demonstrates successful and progressive leadership and initiative. Demonstrates consistently high levels of clinical competence with demonstrated ability to provide clinical interventions at the individual, family, group, system and community level. Ability to function effectively within a multi‑disciplinary team. Demonstrated ability to successfully provide quality patient care considering age‑specific, developmental and cultural needs.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person‑centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.