Social Worker (LMSW)
Posted on: November 15, 2023
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
FMCNA 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 FMCNA Quality
Goals.PRINCIPAL DUTIES AND RESPONSIBILITIES:
- Patient Assessment / Care Planning / Counseling
- As a member of the interdisciplinary team, assesses patients'
psychosocial status, strengths and areas of need that may affect
rehabilitation and optimal treatment outcomes as part of the
comprehensive patient assessment.
- Participates 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.
- Utilizes FKC patient education programs, established social
work theory and methods, social work focused interventions, and
quality of life measurement instruments as part of assessment and
care planning to address barriers and meet patient treatment
- Provides monitoring and interventions for the patient to adjust
to dialysis and achieve optimal psychosocial status and quality of
- Provides supportive counseling services to patients as
permitted within the scope of their clinical training and state
- Provides educational and goal directed counseling to patients
who are seeking transplant.
- Provides information and assists the team and patient with
referral to community resources (home health services, vocational
rehabilitation, etc.) to facilitate optimal treatment
- Maintains 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.
- Assesses patient awareness of advance directives; assists with
accessing advance directive forms/information and facilitates
discussion of advance directive wishes, if necessary, with the
healthcare team and the patient's family/support persons.
- In collaboration with the physician and nurse, participates in
the discussion of patient DNR status in the facility to ensure
patient and/or family understand and make an informed decision
about their care.
- Knowledgeable of and adheres to FMCNA Social Work Policy and
Measuring Patient Physical and Mental Function Policy, including
- Documents based on MSW interaction and interventions provided
to patient and/or family.
- Provides 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
- Participates in monthly Quality review meetings with the
interdisciplinary team. Reports on quality indicators related to
adherence, such as Missed and Shortened Treatments, Quality of Life
Trends, and Service Recovery.
- Patient Education
- Assesses patient knowledge of kidney disease for barriers that
may affect adherence to treatment. Works with patient, family and
health care team to provide education tailored to the patient's
learning style, communication barriers, and needs.
- With other members of the interdisciplinary team, provides
appropriate information about all treatment modalities.
- Facilitates the transplant referral process and collaborates
with interdisciplinary team on transplant waitlist management.
- Provides ongoing education to patient/family regarding
psychosocial issues related to End Stage Renal Disease (ESRD) and
all support services that are available.
- Reviews patient rights and responsibilities, grievance
information (company and network) and other facilities policies
with patient and/or the patients' representative to ensure
patients' understanding of the rights and expectations of
- Collaborates with the team on appropriate QAI activities.
- Patient Admission and Continuity of Care
- Reviews Patient Rights and Responsibilities, Grievance
Procedure & Important Numbers Handout, FKC Non-discrimination
policy, DNR Statement (if applicable) and address any immediate
- Understands the referral and admission process and supports the
clinic in regard to the patient needs for scheduling to maximize
adherence and adjustment.
- The Social Worker will interview the patient to identify root
causes or concerns for the discharge request, (i.e. transfer to
hospice, relocation, dissatisfaction with services or staff) and
share causes/concerns with operational leadership,
- Insurance and Financial Assistance
- Collaborates and functions as a liaison for patient with
Insurance Coordinators to address issues related to insurance.
- In collaboration with Insurance Coordinators, provides
information and education to patients about payment to dialysis
(federal, state, commercial insurance, state renal programs, AKF
HIPP, and entitlement programs).
- Collaborates with the Insurance Coordinator of any changes to
patient state that impacts insurance i.e. transplantation,
discharged, loss of coverage, or extended travel.
- Refers patients to patient billing solutions (PBS) department
for questions/concerns in regard to treatment related bills
- Staff Related
- Assists with interview process and decision to hire new
personnel if requested by SW Manager/Senior Manager.
- Works with the administrative support staff to maintain updated
patient resource lists (e.g. maintain updated list of
- Provides training to staff pertaining to psychosocial topics as
- Contributes and participates with weekly team huddles.
Discusses any urgent patient issues with staff.
- Adheres to work defined caseload guidelines based on state
- Performs other related duties as assigned.PHYSICAL DEMANDS AND
- The physical demands and work environment characteristics
described here are representative of those an employee encounters
while performing the essential functions of this job. Reasonable
accommodations may be made to enable individuals with disabilities
to perform the essential functions.
- Travel required (if multiple facilities)SUPERVISION:
- NoneEDUCATION AND REQUIRED CREDENTIALS:
- Masters in Social Work
- Must have state required license EXPERIENCE AND SKILLS: - - - -
- - - - -
- 2 - 5 years' related experienceEO/AA Employer:
IdentityFresenius Medical Care North America maintains a drug-free
workplace in accordance with applicable federal and state
Keywords: FRESENIUS, Binghamton , Social Worker (LMSW), Healthcare , Vestal, New York
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