Under the direction of the Social Work Manager or designee, the Social Worker will provide medical social work services including: advocating, assessing, assisting, collaborating, counseling, educating, evaluating, implementing and planning for members in various aspects of the member life including but not limited to psychological, psychosocial, financial, environmental and interpersonal matters. In various settings including but not limited to the member’s home, PACE site, different community settings (hospitals, SNF, ALF’s, etc.) The Social Worker will serve as the conduit between the member, the IDT team and other community agencies (acute care institutions, skilled nursing facilities, Assisted Living Facilities, etc.) to ensure the highest level of satisfaction from the start of care throughout their PACE lifetime. The Social Worker will provide support to the PACE member through teaching the adaptation to illness and/or disability and treatment; evaluating psychosocial functioning; psychosocial discharge planning; facilitating the use of services offered by other community agencies; crisis intervention; mental status examinations and supportive counseling with terminally ill patients.
JOB RESPONSIBILITIES :
Provide ongoing casework services to members and their authorized representatives to help them understand accept and follow medical recommendations, to assist them with personal and environmental difficulties which predispose toward illness or interfere with obtaining maximum benefit from the CCM program. To educate members and their authorized representatives in understanding and using community health and welfare resources which help them remain safely in the community (EBT, SCRIE, DRIE, Medicaid, etc.)
The Social Worker will ensure timely and appropriate coordination of care, before, during and after hospitalization to ensure that a member’s wishes regarding his/her care are followed during a hospital stay. Develop discharge plans and ensure that the services the patient requires are in place in order to facilitate a timely and safe discharge to assist with and ensure that the members will be cared for at home.
Ensure that when a member is hospitalized a visit is made within 24-48 hours. To provide support to the member, meet the hospital clinical team to discuss member’s treatment plan and to begin to coordinate the discharge plan. The Social Worker will coordinate the discharge with the PACE staff (reinstating PCW service, transportation coordination with the discharge planner, follow up with the SNF, and other vendors as needed. The Social Worker will conduct a visit to the member within 24-48 hours of discharge.
Provides social work consultation to members and authorized representatives as indicated and requested. Provide education on treatment options and help coordinate services. Arrange bereavement assistance, supportive counseling or other mental health services. The Social Worker is responsible for the completion of psychosocial, MMSE, MOLST, GDS (when applicable),
Completing comprehensive assessments via the McKesson, eCares, Epaces , and other systems as needed .
Organizes work load to insure appropriate and maximum social services to members and authorized representatives. Use case management skills to help members and families address and resolve social, financial, psychological problems related to the member’s health.
The Social Worker is responsible for integrating best social work practices into the total care of the patient by collaborating with other professional personnel within CenterLight Healthcare, in acute care institutions, skilled nursing facilities and other community agencies.
Participates in interdisciplinary patient care conferences, team and family meetings. Responsible for quarterly, annual, significant change assessments, ensuring documentation is completed timely and accurately.
Maintains detailed and up-to-date records on every patient and submit daily reports of his/her activities to the Social Work Manager.
Participates in appropriate continuing education programs sponsored by the Social Work Department, CenterLight Healthcare and applicable outside agencies. Participate in staff enhancement through professional knowledge by attending seminars/workshops relevant to the field of Social Work.
Participates in peer supervision conferences and individual conferences with the Social Work Manager.
Represents the Social Work Department and CenterLight Health System at appropriate meeting and conferences in the community.
All other duties as assigned by Supervisor.
Education: M.S.W. from an accredited college or university
Experience: One year experience in a health care setting. Must have a car for field visits
License: Current certificate and licensure from New York State.