I. SERVICE 100%
1. In general, the incumbent will assist patients and families to:
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Enhance communication with the medical treatment team to enable patients and families to be active partners in their own health care
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Promote Family Centered Care, encouraging families’ active participation in their child’s care
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Deal with crisis
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Identify and solve problems with relationships
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Access medical and community services
2. The incumbent will make assessments of patients with social, emotional, interpersonal and socioeconomic issues. Areas of assessment include:
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Adjustment to illness and treatment
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Ability to follow medical regimen
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Family functioning and communication
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Social and/or financial concerns
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Personal safety including abuse, neglect, violence
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Mental illness/emotional distress
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Adjustment to loss/bereavement
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Cultural, religious, language needs
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Occupation and/or school performance
3. The incumbent gathers information to relay to appropriate personnel regarding counseling/interventions. Interventions may be with patients, families, non-related caregivers, and hospital or community personnel. These may include:
Support during a crisis, medical or otherwise
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Care coordination
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Brief therapy
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Safety planning
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Information and education
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Referral to community agencies
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Advocacy
4. Collects and organizes all relevant information and documentation from referral resources such as parents, caretakers, physicians, DCFS, law enforcement, judicial, Children’s Advocacy Centers, hospitals, schools and other local support agencies in order to provide ongoing case management and support to medical faculty and clinical staff.
5. Assists in locating appropriate services, as well as making appropriate referrals for child and family to include psychologists, school counselors, transportation, financial assistance, housing and other community resources. This requires maintaining a working knowledge of regional social services and other services relevant to this field.
6. Provides education and support that establishes a non-threatening environment.
7. Serves as an advocate for patient and appropriate family members, which include, but is not limited to, facilitating the exchange of information between the medical providers and members of various resource teams.
8. Receives referrals from faculty and residents. Provides counseling services, intakes, school liaison services and coordination with other agencies, in order to meet overall departmental needs.
9. Participates in development and implementation of a patient centered medical home and establishment of an accountable care entity care management.