Job Abstract

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 inunderstanding 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 participants 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 workers 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 met.
• Participate in appropriate continuing education and professional training programs sponsored internally by CenterLight Healthcare 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 CenterLight Healthcare at appropriate meeting and conferences in the community.
• Only act within the scope of the individuals authority to practice.
• Meet a standardized set of competencies for the specific position description established by the PACE organization before working independently.
• All other duties as assigned by supervisor.

QUALIFICATIONS:

Education:M.S.W. from an accredited college or university.

License: LMSW or LCSW required. Must have active NY State Social Work license.

Experience:

• One (1) year experience in a health care setting.
• Minimum of one (1) year of experience working with a frail or elderly population or, if the individual has less than one (1) year of experience but meets all other requirements, must receive appropriate training from the PACE organization on working with a frail or elderly population upon hiring.
• Experience in home care and/or field work is preferred.
• Regular access to a car for field visits is preferred but not required.

Physical Requirements

Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to:

• Standing Duration of up to 6 hours a day.
• Sitting/Stationary positions Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.
• Lifting/Push/Pull Up to 50 pounds of equipment, baggage, supplies, and ability to lift patients safely and using OSHA guidelines, etc.
• Bending/Squatting Must be able to safely bend or squat to care for patients, use medical supplies, etc.
• Stairs/Steps/Walking/Climbing Must be able to safely maneuver stairs, climb up/down, and walk to access work areas Position requires the individual to be able to travel, and walk between sites/locations and work areas throughout the day.
• Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools (ie. typing, use of medical supplies, equipment, etc.)
• Sight/Visual Requirements Must be able to visually assess patients, read orders type/write documentation, etc. with accuracy.
• Audio Hearing and Motor Skills (language) Requirements Must be able to listen attentively and document information from patients, community members, providers, etc., and intake information through audio processing with accuracy. In addition, must be able to speak comfortably and clearly with language motor skills for customers to understand the individual.
• Cognitive Ability Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.