Medical Social Worker - Home Health

Job Summary

Responsible for the provision of direct social work service in Home Health and/or Hospice utilizing the professional healthcare process of assessment, problem identification/planning, action/intervention and clinical goal/outcome evaluation.

Details of the Position

• Providing direct casework services to clients related to their medical/psychiatric diagnosis, including biopsychosocial assessment, assisting with long-term planning and decision making, crisis intervention and short-term therapy.
• Performing holistic evaluation of patient/home, developing an appropriate plan of care, initiating discharge planning, evaluating progress towards goals and monitoring achievement of desired outcomes.
• Providing skilled social work services to patients and education/instruction to patients and caregivers according to the home care/hospice plan of treatment.
• Evaluating patient/home environment as related to holistic healthcare/social needs and making appropriate referrals to other services, agencies and community resources as clinically indicated in collaboration with the case manager and primary physician.
• Collaborating and communicating with other members of the inter/multi-disciplinary team to assure an appropriate and smooth flow of care/services for the patient through the care continuum.
• Evaluating, reviewing, and revising the patient’s social work plan of care on a regular basis and, as clinically indicated, taking prompt action in response to changes in the patient’s health condition in collaboration with the case manager.
• Participating in ongoing discharge planning and care coordination, evaluating interventions and outcomes of social work services by reviewing goals set in plan of care utilizing plan of care and physician’s orders.
• Proactively initiating and participating in patient care inter/multi-disciplinary case conferences and meetings, as well as education and in-service programs.

What You Bring

• Master's Degree Required: Social Work from an accredited school of Social Work
• Minimum of 2 years Preferred: experience in a healthcare setting
• Required: Licensed Master Social Worker - Oregon (Oregon: Minimum requirement)
• Required: Clinical Social Work Associate - Oregon (Oregon: Minimum requirement)
• Required: Licensed Clinical Social Worker - Oregon (Oregon: Exceeds minimum requirement)
• Basic Life Support
• Driver's License and auto insurance

Skills

• Collaborative/cooperative working and communication skills
• Excellent communication skills both verbal and written
• Ability to work effectively with a wide range of patients and caregivers
• Strong organizational skills
• Flexible and able to function independently
• Demonstrated knowledge of community health, welfare, and social agencies
• Ability to apply age-specific principles of growth and development and life stages to meet each patient’s needs for nursing care

Department / Location Specific Notes

• PHOR – Office based Medical Social Worker (in addition to above Essential Functions):
• Assisting clinical staff with assessment of patients and facilitating communication with the IDT, physician and other members of the community healthcare team.
• Assisting staff with development of patient specific interdisciplinary care plans including skilled and non-skilled interventions, measurable and finite goals/outcomes and realistic/appropriate discharge plan.
• Assisting in coordinating services to ensure efficiency in the delivery of patient care services, Agency systems/operations, cost-effectiveness, and timely/accurate communication.
• Assisting in evaluating patient/home environment as related to holistic health care/social needs and making appropriate referrals to other services, agencies and community resources as clinically indicated in collaboration with the case manager, MSW and primary physician.

OSHA

This is a category II job classification per OSHA standards. Normal work involves no exposure to blood borne pathogens, but exposure may be occasionally required.

Working Conditions

• Lifting Ability to move around area with occasional sitting.
• Bend/ twist/ reach/ push/ pull occasionally.
• Lift/Carry: Occasionally up to 5 lbs.

Environmental Conditions

• Exposure to biohazard, body fluids and airborne particles.
• Time spent on site in medical/hospital setting or in office environment.

Mental/Visual

• Vision and hearing required within normal limits (glasses, contacts, hearing aids permitted).
• Ability to communicate and exchange accurate information.

Benefits

• 403b retirement plan for caregiver contributions
• Wellness benefits
• Discount program
• Expanded EAP and mental health program