- Qualification BSW, MSW
Screens, evaluates and performs bio-psychosocial assessments on all referred clients. As an integral component of the patient care team, provide ongoing quality patient-centered services. Work with the team to determine client and family dynamics, needs for additional community services and identify and facilitate access to the appropriate agencies/resources to provide those services. Follow patients across systems of care and provide support throughout the continuum. Provides quality care in a cost-effective manner.
Collaborates with patients and families, physicians, discharge planners, community-based services, and others to implement an appropriate plan of care. Identify key family members who can be coached to provide the necessary support to patient.
Works with RN, Care Coordinator and care givers to educate patients and family caregivers in strategies to improve the effectiveness of their efforts to access needed care and services. Reinforces RN instructions in teaching patient, family.
Works closely with the care team to identify the appropriate high-risk patients for social work intervention. Performs a functional assessment on all high-risk patients to determine patients’ baseline.
Works closely with patients’ care team to identify behaviors impacting change in health status and facilitates appropriate intervention. Visits with patients in the community and provides ongoing telephone support. Works closely with the Area Agency on Aging, Service Coordinators and or other community-based resources to implement additional services to support patients at home.
Maintains accurate and clear documentation on all interventions as well as tracks referrals and collects data to report to agency administrator for outcome measures.
BSW with 5 years social work experience
MSW with 2 years social work experience
Geriatric and/or medical social work experience preferred. Strong biopsychosocial assessment skills. Ability to work with a diverse population. Problem-solving skills. Critical thinking skills. Organizational skills. Time management skills. Active Listening Skills.