Job Summary
- Provide ongoing social work services to participants and their authorized representatives to help them understand and follow care delivery recommendations and to assist them with personal and environmental challenges that predispose them 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 that 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 stays to ensure that a participant's wishes regarding his/her care are followed during that admission. All communication with facilities 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, coordinate with the hospital clinical team to discuss the participant's treatment plan and assist in discharge plan coordination with the PACE IDT.
- 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 (initial, semi-annual, and periodic reassessments), cognitive/emotional status assessments (i.e., GDS, SPMSQ), and other assessments as applicable
- Assist with completion of healthcare proxy documents in coordination with primary care and nursing.
- Assure participant-focused Care Plan for psychosocial goals and interventions applied.
- Utilize EMR for completion of assessments and other systems as needed.
- Ensure documentation is completed in a timely manner (within 24-72 hrs.) and accurately.
- Organize and manage workload to ensure the 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 participants' health. Ensure timely and appropriate coordination and follow through of care and services.
- 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 and 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 met.
- Participate in appropriate continuing education and professional training programs sponsored internally by Kinship Health and/or applicable outside agencies. Participate in staff enhancement through professional knowledge by attending approved seminars/workshops relevant to the field of Social Work.
- Participate in peer supervision conferences and individual conferences with the Social Work Manager/designee.
- Represent the Social Work Department and Kinship Health at appropriate meetings and conferences in the community
Requirements
- Current M.S.W. from an accredited college or university in the state or reciprocity in accordance with state guidelines.
- One (1) year of experience in a healthcare setting with a frail or elderly population is required.
- PACE, SNF experience or Experience in home care and/or fieldwork is preferred.
- Regular access to reliable transportation for field visits is required.
We are EOE
INDKH
Pay: $55,000.00 - $65,000.00 per year
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
Experience:
- PACE, healthcare setting: 1 year (Required)
License/Certification:
Work Location: In person
