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Full/Part Time: Full Time
Location/Affiliates: Mount Sinai Medical Center (Manhattan)
Department: 186 - Social Services
Requisition Number: 14-1606576
PACT [Preventable Admissions Care Team] provides intensified transitional planning for five-weeks post-discharge for patients at high risk for readmission. The goal is to reduce preventable 30-day Hospital readmissions. This program is based on the existing research about how to help those patients at high risk for readmission stay out of the Hospital.
This PACT social worker will provide these services for Medicare and Medicaid Healthfirst beneficiaries across the Mount Sinai Health System.
The role of the PACT social worker is to do an enhanced biopsychosocial assessment of both the patient and the family caregiver during the hospitalization; to collaborate with the floor social worker responsible for the discharge and with the interdisciplinary team as needed; to refer appropriate patients to the IMA High Risk Clinic; to provide regular follow-up phone calls to patients enrolled in the program and to family caregivers, physicians, and/or other service providers as indicated. The social worker is responsible for ensuring that the patient receives timely follow-up with the outpatient primary care physician, including collaborating with the primary care physician as needed to secure an appointment and addressing any barriers to keeping follow-up appointments post-discharge and adhering to the prescribed medication regimen; contacting the patient and family post-discharge and prior to the first follow-up appointment to ensure that the patient attends the post-discharge follow-up appointment as scheduled; and providing on-going phone contact and/or home visits if necessary with the patient and the family to address all issues impacting the potential for preventable readmissions.
New York State LMSW or LCSW required.
Exceptional skills in engaging patients and families and in assessment and coordination of resources within families and hospital and community networks for effective management of patient care.
Exceptional organizational, collaborative and psychosocial assessment and intervention skills.
Interest in being part of an innovative initiative to improve the quality of care by addressing preventable readmissions.
Hospital experience and experience with patients with chronic illness.
Mount Sinai Medical Center is an equal opportunity/affirmative action employer. We recognize the power and importance of a diverse employee population and strongly encourage applicants with various experiences and backgrounds. Mount Sinai Medical Center--An EEO/AA-D/V Employer.