Social Worker
- Supervised by: Center Director
- Supervises: None
Job Summary:
Under the supervision of the Center Director plans, organizes, and implements social work services for PACE participants and families. Responsibilities include but are not limited to: participant social work assessment and treatment and teaching and counseling of participant, caregiver or other appropriate representatives/family to maintain participant support in the community. The Social Worker is the liaison between the interdisciplinary team, caregiver representatives, and community agencies.
Qualifications and Requirements:
Education • Training • Certifications
- Master’s degree in social work from an accredited school of social work
- Member of the Academy of Certified Social Workers (ACSW) or other NASW-recognized certification preferred
- Current driver’s license and proof of auto insurance
- Licensed by the California Board of Social Work Examiners and shall comply with the Social Workers’ Licensing Act of 1991
Experience:
Two (2) years of experience working on an interdisciplinary team in a hospital, nursing home or community-based setting is preferable.
Medical Clearance:
Employees must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.
Competency:
Position specific competencies for the Nurse Practitioner will be met prior to assuming participant care.
Physical Demands and Working Conditions:
The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. In compliance with ADA requirements, reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.
Work Environment:
Employee must be able to work effectively within an interdisciplinary team model, interfacing and collaborating with a wide range of clinical and social services disciplines who work together to manage the PACE participants’ care. The work setting is in an Adult Day Health Center and primary care clinic environment with moderate noise levels and controlled temperatures.
Physical Requirements:
Requires corrected vision and hearing to normal range. Must be able to communicate with all staff, vendors, and clients. Requires manual and finger dexterity and eye-hand coordination; the ability to use department equipment. Requires lifting/carrying up to 65lbs.and pushing or pulling 150lbs.using appropriate body mechanics and equipment, with reasonable accommodation if needed.
Visual, Hearing and Communication Requirements:
Requires corrected vision and hearing to normal range, with or without reasonable accommodation. Ability to communicate by way of the telephone with participants, customers, vendors and staff.
Pressure Factor:
Requires working under stressful conditions. Working conditions may be noisy and crowded and fluctuating indoor temperatures. Moderate pressure to meet scheduled deadlines. Potential for exposure to verbal aggression by client, vendors, and staff.
Environmental Conditions:
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.
Skills and Knowledge:
- Familiarity with the psycho-social issues of the frail and chronically ill and their caregivers.
- Ability to provide psychosocial assessment and individual, family and group counseling.
- Ability to maintain accurate records and to prepare clear and concise reports, correspondence and other written materials.
- Good public speaking skills with all size groups.
- Effective verbal and written communication skills.
- Demonstrated ability to work in an interdisciplinary team setting.
Duties and Responsibilities:
Conduct in person initial, scheduled, and unscheduled reassessments per policies.
Collaborate with the interdisciplinary team to develop a comprehensive care plan for each participant.
Maintain regular attendance at and participate in daily Interdisciplinary Team meetings, communicate participant changes and collaborate with team members in care planning decisions and coordination for 24-hour care delivery.
Act as the liaison between the interdisciplinary team, caregiver representatives, and community agencies. Assist with locating resources.
Assess mental health needs.
Provide ongoing support, counseling, and education to participants and caregivers 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.
Work proactively to maintain participant housing through intervention with participant, caregivers, and housing. Provide referrals to subsidized housing and assisted living residences including, completing applications, obtaining medical records, accompanying participants to interview assessments and tours if participant has no other support systems or to assist caregivers.
Assist participant to function at most independent community level possible.
In collaboration with other members of the Interdisciplinary Team, coordinate admission/discharge to contracted facilities for temporary respites and permanent placement.
Perform home visits as needed to assess living environment and support system.
Perform visits at hospital within 24 hours of admission or on Monday if participant is admitted on Friday or weekend. Coordinate hospital discharges in conjunction with PACE primary care providers and interdisciplinary team Communicate with family or caregivers frequently and as needed to update on discharge plans.
If end of life care is appropriate, actively provide emotional support, grief counseling, education, and funeral/financial planning referral. Facilitate end of life or nursing home placement as needed.
On an annual basis present the written participant rights documentation to participant and/or caregiver. In the event the participant is unable to understand the information, the social worker will ensure the caregiver or designated representative understands the participant rights. If there is a language barrier, the Social Worker will use an interpreter.
Initiate referrals to external resources with community agencies such as Adult Protective Services, Housing Authority, or public utility companies. Advocate for participants with these entities for purposes of maintaining community stability.
Assist participants with Social Security Income (SSI) and Social Security Disability Insurance (SSDI) application process as needed.
In collaboration with eh primary care provider, assist participants and caregivers to complete Medical Durable Power of Attorney (MDPOA), Proxy, and Do Not Resuscitate (DNR) directives as needed.
Assist participants and family in keeping resources within guidelines for Medicaid eligibility and assistance if needed with annual Medicaid application.
Attend and actively participate in a variety of organizational meetings related to participant care or daily operations, in-services, and community agency meetings.
Act as a resource to other team members and day center staff regarding topics such as dementia, difficult behaviors, and difficult personalities.
Complete all documentation of services and interventions in participants’ medical records.
Assist participants disenrolling from PACE in coordinating insurance and referrals for other community or facility-based services as desired by the participant.
In the event of termination of enrollment in [Asian Heritage Healthcare], the social worker will act to coordinate the transitional care necessary to ensure continuation of care during and after termination. Assist participants in obtaining reinstatement in conventional Medicare and Medicaid benefits, transition to other care providers, make referrals to other community-based or facility-based providers, assist in providing the participants’ medical records to new providers with participant approvals.
Act only within the scope of his or her authority to practice.
Follow all Policies and Procedures and OSHA safety guidelines.
Protect privacy and maintain confidentiality per HIPAA regulations of all company procedures, results and information about employees, participants, and families.
Practice standard precautions.
Maintain safe working environment, following PACE safety policies and procedures.
Participate in and support Quality Improvement initiatives
Participate in continuing education classes and any required staff and training meetings.
Maintain professional affiliations, required certifications and continuing education requirements.