Social Worker (LMSW, LCSW) - HomeCare

Job Responsibilities

• Collaborates with the interdisciplinary team regarding patients that were identified for Social Work Services, and through IDT/case communication, assists with identifying patients that would benefit from Social Work Services.
• Completes Comprehensive In-home Psychosocial Evaluations. Evaluations Include Consideration of developmental, social and/or cultural, substance abuse, psychological, environmental, and medical issues
• Physical, social, emotional, and familial characteristics
• Use of evidence-based assessment tools to determine cognitive status and behavioral health needs including Dementia, Depression, Anxiety, etc.
• Home safety, family dynamics, caregiver strain, and other risk factors including suicide
• Patient/family understanding of their disease treatment options
• Strengths, available supports, and barriers to care
• Determine appropriate level of care including needs for long/short-term skilled-nursing facilities, assisted living facilities, adult day care, etc.
• Based on a comprehensive, culturally competent assessment collaborates with the patient and family to create a care plan with measureable goals.
• Implements short-term interventions to address identified barriers and promote health and well-being.
• Provides clinical treatment services in form of triage, crisis intervention, individual or family therapy, screening and planning
• Utilize Motivational Interviewing and Coaching skills to assist patients/families in identifying and addressing goals.
• Using identified strengths, encourage self-determination and independence
• Act as educators for patients, families, the community, and other professionals regarding disease prevention, disease progression, impact of illness, health maintenance, and adherence to treatment regimens
• Advocate for the needs and interests of patients to improve access to care and improved delivery of services
• Ongoing assessment of patient and family needs.
• Maintain timely documentation of social work services, which reflect the patient and client systems’ pertinent information for assessment and treatment; social work involvement and outcomes.
• Facilitates team based care and collaboration
• Work collaboratively with primary care and specialty physicians and other members of the health care team to improve quality of life
• Functions as an integral member of the multidisciplinary team.
• Participates in case conferences and IDT meetings
• Affords the health care team in understanding social/psychological factors related to patient’s care
• Acts as a consultant for Agency staff regarding abuse, neglect, exploitation, and community resources
• Identify HHC and community-based resources for patients and families as appropriate

Qualifications

• 2-3 years health care experience, inclusive of acute and community health experience
• Licensure, Certification, Registration LMSW Required, LCSW Preferred
• Considerable knowledge of social, cultural, economic, political, religious, medical, psychological and legal issues which influence the behaviors of patients and families.
• Familiarity with various evidence-based assessment tools: PHQ-9/PHQ-2, SLUMS, BIMS, FAST, SAD Caregiver Strain Index, etc.
• Knowledge of and ability to obtain community resources (town/state/federal programs and eligibility requirements)