Master Social Worker - MSW

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 (QAI) Activities. This is an entry level MSW role.

Patient Assessment / Care Planning / Counseling

• 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.
• Utilizes patient education programs, social work theory and methods, social work focused interventions, and quality of life measurement instruments.
• Provides monitoring and interventions for the patient to adjust to dialysis and achieve optimal psychosocial status and quality of life.
• Provides supportive counseling services to patients within the scope of clinical training and state license.
• Provides educational and goal directed counseling to patients seeking transplant.
• Assists the team and patient with referral to community resources such as home health services and vocational rehabilitation.
• Maintains knowledge of local vocational/educational rehabilitation programs and assists patients with referral and access.
• Assesses patient awareness of advance directives and facilitates discussion of advance directive wishes.
• Participates in the discussion of patient DNR status in collaboration with the physician and nurse.
• Adheres to Social Work Policy and Measuring Patient Physical and Mental Function Policy, including documentation.
• Documents based on MSW interaction and interventions provided to patient and/or family.

Quality

• Provides psychosocial support and/or 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 and reports on quality indicators related to adherence.

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 appropriate information about all treatment modalities with the interdisciplinary team.
• Facilitates the transplant referral process and collaborates on transplant waitlist management.
• Provides ongoing education to patient/family regarding psychosocial issues related to End Stage Renal Disease (ESRD) and available support services.
• Reviews patient rights and responsibilities, grievance information and other facility policies with patient and/or representative.
• Collaborates with the team on appropriate QAI activities.

Patient Admission and Continuity of Care

• Reviews Patient Rights and Responsibilities, Grievance Procedure, Non-discrimination policy, DNR Statement and addresses immediate needs/concerns.
• Understands the referral and admission process and supports the clinic with patient scheduling to maximize adherence and adjustment.
• Interviews the patient to identify root causes or concerns for discharge requests and shares concerns with operational leadership.

Insurance and Financial Assistance

• Collaborates and functions as a liaison for patient with Insurance Coordinators to address insurance issues.
• Provides information and education to patients about payment to dialysis including federal, state, commercial insurance, state renal programs, AKF HIPP, and entitlement programs.
• Collaborates with the Insurance Coordinator on changes to patient status that impact insurance.
• Refers patients to patient billing solutions department for treatment related bill questions.

Staff Related

• Assists with interview process and decision to hire new personnel if requested by SW Manager/Senior Manager.
• Works with administrative support staff to maintain updated patient resource lists.
• Provides training to staff pertaining to psychosocial topics as needed.
• Contributes and participates with weekly team huddles and 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

Travel required (if multiple facilities or home visits, if applicable).

Supervision

None.