SOCIAL WORKER

JOB PURPOSE:

Under the direction of the Social Work Manager, the Social Worker will provide social work services including: advocating, assessing, assisting, collaborating, educating, evaluating, implementing and planning for participants in various aspects of the participant's life including but not limited to psychological, psychosocial, financial, environmental, and interpersonal matters. Social work engagement takes place in various settings including but not limited to the participant's home, PACE site, community settings (hospital, SNF, ALF, etc.).

The Social Worker will serve as a conduit among the participant/authorized representative, the Interdisciplinary Care Team and other community agencies (hospital, SNF, ALF, APS etc.) to ensure the highest level of satisfaction throughout the PACE lifecycle. The Social Worker will provide support to the PACE participant, including but not limited to concrete services, adjustment to illness/disability/treatment, crisis intervention, and end of life care. The Social Worker will assess and evaluate psychosocial functioning; conduct mental status assessments; participate in discharge planning; and enlist collateral community agencies’ services as applicable.

JOB RESPONSIBILITIES:

• Provide ongoing social work services to participants and their authorized representatives to help them understand and follow care delivery recommendations; to assist them with personal and environmental challenges which predispose toward illness or interfere with obtaining maximum benefit from the PACE program.

• Educate participants and their authorized representatives in understanding and using community, health and public services and benefits which help them remain safely in the community (SNAP, SC/DRIE, Medicaid, Medicare, housing, etc.) and assist with making referrals, coordinating services and completing related documents as needed.

• Ensure timely and appropriate communication and coordination of care during/post hospitalization, or other inpatient stay, to ensure that a participant's wishes regarding his/her care are followed during that admission. All communication with facilities, hospital/STR, will be reported to the IDT and documented.

• Ensure telephonic outreach is made within 24-48 hours of hospitalization, and regularly thereafter during admission, to provide support to the participant, to coordinate with the hospital clinical team to discuss participant's treatment plan, and to assist in discharge plan coordination with the PACE IDT. The Social Worker will also conduct a visit to the participant within 72 hours of discharge (business days) to assess for any psychosocial issues that may contribute to re-hospitalization.

• Provide social work consultation to participants and authorized representatives as indicated. Provide education on treatment options, including palliative and end of life care, and help coordinate services. Arrange bereavement assistance, supportive counseling, or other behavioral health services as needed. Provide caregiver support as needed.

• Complete biopsychosocial assessments (semi-annual, quarterly revisit, PRN, SOC, ROC, SCIC, SDR), cognitive/emotional status assessments (i.e. GDS, SPMSQ) and other assessments as applicable. Complete HCP document and facilitate completion of advance directives, such as the DNR/DNI/DNH/MOLST documents.

• Assure participant-focused Care Plan psychosocial goals and interventions are applied.

• Utilize EMR for completion of assessments and other systems as needed.

• Ensure documentation is completed timely (within 24-72 hours) and accurately.

• Organize and manage workload to ensure provision of appropriate and maximized social services to participants and authorized representatives. Use case management and clinical skills to help participants and families address and resolve social, financial, and psychological problems related to the participant's health. Ensure timely and appropriate coordination and follow-through of care and services.

• Responsible for integrating best practices into the participant’s total care by collaborating with other professional personnel within CenterLight Healthcare, in acute care institutions, skilled nursing facilities, and other community agencies.

• Facilitate psycho-educational presentations for the participants in the day health centers. Presentations will be for educational purposes and to promote the social worker’s role in the IDT.

• Attend and actively participate in IDT and care plan meetings.  Identify, document as part of the care plan and present social work-related concerns and/or issues and appropriate social work interventions and recommendations. Ensure social work interventions are applied and participant-centered goals are