Social Worker

About the Role

Responsible for providing direct social work case management services to the Senior Total Life Care (TLC) participants in a home and community-based model of care. Provides social services support including participant screening, case management, and referral. Links participants with appropriate community resources. Makes home visits to private homes of STLC participants, which may necessitate frequent travel. Reports directly to the Center Manager.

Responsibilities

• Participates in the Interdisciplinary Team's initial assessments, care planning, and periodic re-assessments (minimally every 6 months) of participants’ cases. Assessments are to be completed prior to the scheduled team meeting.
• Maintains current written case management records, including periodic reassessments of program participants.
• Provides individual and family counseling, develops and leads group counseling and activities.
• Assists and advocates for participants’ access to services.
• Refers participants and families to appropriate community agencies or facilities, acting as a liaison with such organizations and as an advocate for participants.
• Consults with and advises staff members as to the relationship of social, emotional, and cultural factors to health and medical care, and as to the availability of social services in the community.
• Assists with coordination of 24-hour care delivery.
• Documents participant changes appropriately in the medical record and communicates participant changes to team members as needed.
• Updates participants’ care plans appropriately throughout the reassessment period.
• Participates, collaborates, and contributes as a member of the Interdisciplinary team (IDT).
• Emphasizes teamwork and collaboration in all clinic and Interdisciplinary interactions.
• Supports his/her Interdisciplinary Team (IDT) and promotes unity among the team while interacting with the team, other co-workers, and/or participants.
• Participates in participant care planning including the implementation of SMART goals/interventions for the participants’ care plans and enters all care plan information in a timely manner as per organizational protocols.
• Supports Senior TLC’s mission to encourage and support the quality of life of seniors wishing to continue living in the community; its vision to be the preferred provider of individualized care for seniors in the community; and its values of respect, integrity, accountability, compatible goals, and compassionate care.
• Other duties as assigned.

Requirements

• Master's Degree from an accredited School of Social Work required.
• 2 years experience in a health related area preferred.
• Minimum of 1 year experience working with the frail elderly population.
• A valid NCDL and vehicle.
• Individual therapy skills for geriatric participants, analytical thinking, and problem-solving abilities.
• Experience in linking clients with appropriate community resources.
• Only act within the scope of his or her authority to practice.
• Meet a standardized set of competencies for the specific position description established by Senior TLC and approved by CMS before working independently.
• Be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact.

Skills

• Providing direct social work case management services.
• Participant screening and referral.
• Home visits and community resource linkage.
• Interdisciplinary team collaboration and care planning.
• Individual and group counseling for geriatric participants.