Social Worker MSW

Overview

Provides comprehensive social work services to PACE participants. Responsibilities include, but are not limited to, continual psychosocial evaluation and intervention; assessment for admission and ongoing eligibility, patient rights and advocacy function, daily case management, individual/group and family counseling as appropriate. Is a key member of the PACE Interdisciplinary Care Team.

Responsibilities

Job duties specific to this position: Presents social work concerns and issues, suggestions for intervention(s) and recommendations for the treatment plan of individual participants to interdisciplinary team. Confers with the participant and family (as appropriate) regarding individual expectations plus long and short term goals; attends/coordinates family meetings; attends nursing home care planning meetings, etc. as appropriate. Attends morning meeting; during morning meeting, reviews significant events/occurrences as related to family, finance, and psychosocial/behavioral changes with interdisciplinary team; makes recommendations for appropriate interventions/care plan changes.

Intervenes in crisis; attends to the emergency needs of the client and/or family relating to illness, disability, deterioration of independence, etc.; advocates participants needs, wishes and right to self-determination. Participates in the development and revision of the participants’ plan of care as a member of the Interdisciplinary Team; integrates the Social Work treatment plan into the overall plan of care developed by the Interdisciplinary Team.

Assesses the participant, family and home environment for areas where social work planning and interventions can be of assistance; maintains required documentation in the EMR (Electronic Medical Record) regarding participants care and progress within the specified timeframe. Assists in determining participant and family needs related to social supports, psychological supports, financial supports and/or counseling as well as housing options/alternatives. Collaborates with the participant and family in making necessary applications for public assistance, housing placement, pre-admission screening, etc.

Performs pre-enrollment assessment of potential enrollees, the initial assessment; develops a treatment plan in cooperation with participant, family, and team members; performs a semiannual and annual assessment and develops an individualized plan of care for the next six months; attends Intake & Assessment meetings, and clinical case conferences as appropriate. Maintains active communication with other team members and nursing homes to discuss progress and coordination of client care efforts. Assists in the development and implementation of social work policies and procedures; in collaboration with QAPI Coordinator is actively involved in QAPI program and serves on task forces as requested.

Educates other team members regarding community resources, Medicaid and other social program and psychosocial issues related to…

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