This position provides comprehensive care coordination for patients and families, supporting a holistic and coordinated approach across the continuum of care. This position assesses psychosocial aspects of care adding to the treatment plan, providing individual and group psychotherapy, assists with disease management and education to enhance informed decision-making; collaborates with an interdisciplinary team to allow for timely treatment and increased supportive care throughout the patient/family experience. This position provides individual assistance to patients, families and caregivers to help identify and overcome barriers which may hinder quality medical and psychosocial patient care.
Assesses and manages the patient/family plan of care for the identification and facilitation of resources required during the progression of the chronic condition in order to achieve the optimal clinical, financial, operational, and satisfaction outcomes.
Acts in a leadership function with process improvement activities to develop and execute uniquely designed programs for dementia patients and families in order to achieve the optimal clinical, financial, operational, and satisfaction outcomes.
Assists the patient/family through the course of dementia using disease management precepts to provide ongoing education, psychosocial support and counseling to assist with adjustment for the patient and family.
Coordinates the plan of care using an interdisciplinary holistic approach, making appropriate medical, legal, social and financial referrals and consultations in coordination with physicians and other team members.
Ensures that the patient and family understand the dementia diagnosis, disease progression and behavioral strategies and recommended actions, and are provided with appropriate information in coordination with physician and health care providers. Responds to patient/family requests for ongoing information and education regarding the disease process, legal, financial and community resources including respite and residential care options to optimize outcomes. Supports the patient and family during difficult decision-making periods. Assists/facilitates the completion of patient health care directives providing education and emotional support to families.
Evaluates patients functional, cognitive and emotional abilities and limitations. Determines when intervention is needed. Establishes treatment goals that are measurable reflecting patient/family key limiting factors. Establishes and implements a plan of care to achieve treatment goals. Collaborates with patient and family when setting goal.
Educates internal members of the health care team on care coordination of dementia patients/families in the community. Participates in staff development to maintain current standards of practice and ensure the highest quality of care.
Establishes and promotes a collaborative relationship with physicians, payers, and other members of the health care team. Collects and communicates pertinent, timely information to payers and others to fulfill utilization and regulatory requirements.
Must possess knowledge as normally obtained through the completion of a Masters Degree in Social Work with additional licensure in Arizona as a Licensed Clinical Social Worker required.
Requires a proficiency level typically achieved with 5 years clinical experience. Requires excellent organizational skills and clinical knowledge regarding specialty care services, as well as care coordination of services, legal and financial aspects of diagnostic services and health services in specialty area. Requires effective communication and writing skills, good time management skills and knowledge of word processing and database software applications. Requires the ability to teach both clinical and non-clinical personnel regarding care and diagnostics services. Also requires a good understanding of process improvement.
Must having a working knowledge of dementia care precepts. Has created individual and group treatment plans conducting both individual, family and group psychotherapy.
Additional related education and/or experience preferred.
Internal Number: 248176
About Banner Health
You want to change the health care industry – one life at a time. You belong here. You’re excited to be part of the dramatic changes happening in the health care field. In fact, you thrive on change. But you also understand that excellent, compassionate patient care is the true measure of the success of these changes. You belong at Banner Health. Our award-winning, comprehensive health system includes 23 hospitals in seven western states, primary care health centers, research centers, labs, a network of physician practices and much more. Throughout our system, skilled, compassionate professionals use the latest technology to change the way care is provided. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages: •Our vision for changing the future of health care gives you the opportunity to leverage your abilities to achieve something historic. •Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health. Our system also includes hospitals specializing in cancer, heart health and pediatrics. •Our many loc...ations also translate into a broad selection of exciting and rewarding lifestyle options – from the big city to the wide-open spaces. •Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible. •The size, success and growth of our system provide you with the stability and options to pursue your desired career path. •Our competitive compensation and comprehensive benefits offer you options to complement your unique needs.