Under the supervision of the Center Manager plans, organizes and implements social services to Senior CommUnity Care participants and families. Responsibilities include but are not limited to: assessment, treatment, teaching and counseling to participant, caregiver or other appropriate representatives. The Social Work interventions could include individual participant contacts; appropriate collateral contacts; participant and family education, assessment and counseling; provision of resources; ongoing case management; advocacy to ensure participant and caregiver needs are met and addressed; and disenrollment procedures. The Social Worker is the liaison between the Interdisciplinary Team (IDT), caregiver representatives, and community agencies.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge required. This position requires a Masters in Social Work (MSW).
- Must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.
- Must have a valid driver's license and have means of transportation.
- Must clear background check.
- Education: Masters Degree from an accredited school of social work required. Be legally authorized, currently licensed, registered or certified if applicable in the state of employment.
- Experience: A minimum of one year's experience working with frail or elderly population required. Experience working on a multi-disciplinary team in a hospital, nursing home or community-based setting is preferable.
- Skills and Knowledge:
- Experience with frail/chronically ill elderly people.
- Ability to provide psychosocial assessment and individual, family and group counseling.
- Effective verbal/written communication skills with the ability to maintain accurate records and to prepare clear and concise reports, correspondence and other written materials.
- Training and/or mentoring experience and ability to complete performance objectives, measures and evaluations.
- Good public speaking skills with all size groups.
- Ability to communicate clearly and effectively verbally and written.
- Ability to utilize computers and other electronic devices for tasks such as timekeeping, in-servicing and documentation.
- Only acts within the scope of his or her authority to practice. Must meet a standardized set of competencies for the specific position description established by Senior Community Care and approved by CMS before working independently.
- Performs in person initial assessments for enrollment of potential Senior CommUnity Care participants to obtain a complete psychosocial history, which may include descriptions of cognitive status, social supports, family dynamics mental health and substance dependency and other issues and needs. Coordinates with the Interdisciplinary Team to develop a comprehensive plan of care for each participant.
- Conducts in person re-assessment of enrolled participants every six (6) months and as needed.
- Functions as a member of the Interdisciplinary Team. Maintains regular attendance at and participates in Interdisciplinary Team meetings; communicates participant changes, collaborates on plan of care decisions and coordination for twenty-four (24) hour care delivery.
- Provides ongoing support, counsel, and education to participants and family regarding a variety of issues, including but not limited to: the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics and changing roles, PACE model and PACE health services.
- Presents requests to Interdisciplinary Team for and coordinates admission/discharge to contracted facilities for temporary respites and permanent placement.
- Acts as facilitator for meetings with participant, family, caregivers, and community agencies to clarify, or problem solves issues regarding the plan of care. Mediates discussions between all parties.
- If hospice care is appropriate actively provides emotional support, grief work, education and funeral/financial planning referral. Facilitates hospice or nursing home placement as needed. Initiate referrals to external resources with community agencies such as Adult Protective Services, Housing Authority, or public utility companies. Advocates with these entities for purposes of maintaining community stability.
- Assists participants and caregivers to complete Medical Durable Power Of Attorney (MDPOA) Proxy, and Do Not Resuscitate (DNR) directives as needed.
- Attends and actively participates in a variety of organizational meetings related to participant care, including but not limited to: Morning Meeting, Intake and Assessment Meeting, various in-services and community agency meetings.
- Acts as a resource to other team members and day center staff regarding topics such as dementia, difficult behaviors, and difficult personalities.
- Completes and ensures completion of documentation of clinical service, in participant's medical records including initial assessments, re-assessments, change of status, temporary or permanent placements; hospital admissions and discharges, home and nursing home visits and other significant events according to Senior CommUnity Care documentation requirements.
- Assists participants and caregivers in filing grievances.
- Acts within scope of his or her authority to practice.
- Follow all Senior CommUnity Care policies and procedures and Occupational Safety and Health Administration (OSHA) safety guidelines.
- Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants, and families.
- Maintains safe working environment. Follows Senior CommUnity Care Safety policies and procedures.
- Participates in and supports Quality Improvement Initiatives.
- Participates in continuing education classes and any required staff and training meetings. Maintains professional affiliations and any required certifications.
- Performs other duties as required.
The work environment characteristics described here are representative of those an employee may encounter while performing the essential functions of this job. Reasonable accommodations may be made to enable individual with disabilities to perform the essential functions:
- May be exposed to a risk of bodily injury through contact with moving instrumentation, toxic substances, medicinal preparations, bodily fluids, communicable diseases and any other conditions common in a healthcare environment.
- Subject to unpleasant odors.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individual with disabilities to meet these demands:
- Physical Requirements - Shall be in good mental and physical health, and capable of performing assigned tasks. Requires standing, walking, occasional pushing and pulling and lifting. Requires the ability to lift/carry up to fifty (50) pounds and push or pull objects exceeding one hundred fifty (150) pounds, using appropriate body mechanics. Requires manual and finger dexterity and eye-hand coordination.
- Visual, Hearing and Communication Requirements - Requires corrected vision and hearing to normal range, with or without reasonable accommodation. Must be able to document care provided in participant records. Must be able to communicate verbally with participants, family and team.
- Pressure Factor - Requires working under stressful conditions. Working conditions may be noisy and crowded and fluctuation indoor temperatures. Required to meet scheduled appointments while dealing with frail and confused participants. Subject to participants that may have the potential for verbal or physical aggression as well as difficult family dynamics, including caregivers under stress.
Safe Work Performance Expectations
The safety of employees, residents and visitors is of paramount importance. Our work place safety program will be incorporated as the standard of practice for this organization. Compliance with these safe work expectations will be required of all employees as a condition of employment. Our organization focus will hold all employees accountable for safety performance equal with quality and production expectations.
Employees will be expected to:
- Follow correct policy and procedures for department and facility Fire/Disaster/Missing Person Plan. Know the location of fire alarms and extinguishers.
- Follow correct policy and procedure for hand washing.
- Follow guidelines for proper method of lifting.
- All doorways, hallways and areas are to be kept clear.
- Know the location and purpose of Material Safety Data Sheets (MSDS).
- Follow guidelines for department environment and safety measures.
- Follow guidelines for safe handling, inspection, maintenance and storage of equipment. Report any malfunction of equipment.
- Follow guidelines for safe handling and storage of chemicals and supplies.
- Follow correct policy and procedure for reporting of incidents: staff, residents, etc.
Every effort has been made to identify the essential functions of this position. However, this job description in no way states or implies that these are the only duties you may be required to perform. The omission of specific descriptions of duties does not exclude them from the position if the work is similar, related or can be considered essential to this position.