Social Worker
Current• Assess health status, level of functional independence, medical needs, and rehabilitation potential for all patients. • Assess patient's need for supportive counseling, provide adjustment support (in relation to affliction, and refer for additional mental health services as needed.• Provide ongoing re-assessment throughout the rehabilitation process.• Identify real and potential problems requiring interventions prior to moving the patient to the next level of care. • Establish and maintain effective relationships with third-party payers, external case managers, or other insurance liaisons to effectively manage use of resources. • Record in medical record necessary information to keep health care team apprised of goals, progress, and outcomes.• Educate patients and families regarding plans of care, care alternatives, and potential outcomes in order to collaboratively develop, coordinate, and implement a feasible and effective discharge plan.• Facilitate patient/family education with the rehabilitation team.