Master Social Worker

Purpose and Scope

Provides psychosocial services to patients treated by the facility including in-center and home dialysis patients 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 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. Supports the Fresenius Kidney Care commitment to Quality Indicators and Outcomes and Quality Assessment and Improvement activities. This is an entry level MSW role.

Patient Assessment / Care Planning / Counseling

• Assesses patients' psychosocial status, strengths and areas of need as part of the comprehensive patient assessment.
• Participates in care planning with the patient and healthcare team to identify effective interventions.
• Utilizes patient education programs, social work theory and methods, and quality of life measurement instruments.
• Provides monitoring and interventions to help patients adjust to dialysis and achieve optimal psychosocial status.
• Provides supportive counseling services within the scope of clinical training and state license.
• Provides educational and goal directed counseling to patients seeking transplant.
• Assists with referral to community resources such as home health services and vocational rehabilitation.
• Assesses patient awareness of advance directives and facilitates discussion of wishes with the healthcare team and family.
• Participates in discussion of patient DNR status with physician and nurse.
• Documents MSW interactions and interventions per policy.

Quality

• Provides psychosocial support and Social Work Focused Interventions to address non-adherence, quality outcome, and quality of life concerns.
• 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.
• Provides education tailored to the patient's learning style, communication barriers, and needs.
• Provides information about all treatment modalities with the interdisciplinary team.
• Facilitates the transplant referral process and collaborates on transplant waitlist management.
• Provides ongoing education regarding psychosocial issues related to End Stage Renal Disease and available support services.
• Reviews patient rights and responsibilities, grievance information, and facility policies.

Patient Admission and Continuity of Care

• Reviews Patient Rights and Responsibilities, Grievance Procedure, non-discrimination policy, and DNR Statement.
• Understands the referral and admission process and supports clinic scheduling needs.
• Interviews patients to identify root causes or concerns for discharge requests and shares concerns with operational leadership.

Insurance and Financial Assistance

• Collaborates as a liaison for patients with Insurance Coordinators to address insurance issues.
• Provides information and education about payment to dialysis including federal, state, commercial insurance, state renal programs, AKF HIPP, and entitlement programs.
• Collaborates with Insurance Coordinator on changes impacting insurance such as transplantation, discharge, loss of coverage, or extended travel.
• Refers patients to patient billing solutions for treatment-related bill questions.

Staff Related

• Assists with interview process and hiring decisions if requested by SW Manager/Senior Manager.
• Maintains updated patient resource lists with administrative support staff.
• Provides training to staff on psychosocial topics as needed.
• Contributes and participates with weekly team huddles.
• Discusses urgent patient issues with staff.
• Adheres to work defined caseload guidelines based on state regulatory requirements.
• Performs other related duties as assigned.

Physical Demands and Working Conditions

The physical demands and work environment characteristics described 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 or home visits, if applicable).

Supervision

None.