Social Worker MSW - HomeCare

About the role

The Home Care Social Worker (MSW/LMSW) is a Master’s prepared, Licensed/License eligible Clinician who engages patients in their home to determine their short and long-term needs and provides short term interventions to meet patient's goals of care.

Responsibilities

• Determines short and long-term needs of patients and provides interventions to meet those needs.
• Collaborates with patients, their families, physicians, and home care team to identify and address patient’s bio-psychosocial needs, barriers to care, risk-factors, etc.
• Completes comprehensive in-home psychosocial evaluations, considering developmental, social and/or cultural, substance abuse, psychological, environmental, and medical issues.
• Evaluates physical, social, emotional, and familial characteristics, using evidence-based assessment tools to determine cognitive status and behavioral health needs including Dementia, Depression, Anxiety, etc.
• Identifies and addresses patient and family understanding of disease treatment options, strengths, available supports, and barriers to care.
• Determines appropriate levels of care, including needs for long/short-term skilled-nursing facilities, assisted living facilities, adult day care, etc.
• Collaborates with interdisciplinary team to identify patients that would benefit from Social Work Services and assists in creating care plans with measurable goals.
• Provides clinical treatment services such as triage, crisis intervention, individual or family therapy, screening and planning, utilizing Motivational Interviewing and Coaching skills.
• Encourages self-determination and independence by utilizing identified strengths.
• Acts as an educator for patients, families, the community, and other professionals regarding disease prevention, disease progression, impact of illness, health maintenance, adherence to treatment regimens, and accessing short and long-term community resources.
• Advocates for the needs and interests of patients to improve access to care and improve delivery of services.
• Maintains timely documentation of social work services reflecting pertinent information for assessment and treatment, social work involvement, and outcomes.
• Facilitates team-based care and collaboration, working with primary care and specialty physicians, other members of the health care team to improve quality of life and meeting patient’s goals of care.
• Participates in case conferences and IDT meetings, acting as a consultant for Agency staff regarding abuse, neglect, exploitation, and community resources.
• Identifies and facilitates access to HHC and community-based resources for patients and families as appropriate.

Requirements

• Master’s Degree in Social Work
• 1 - 2 years clinical experience in a healthcare setting
• Licensure required within 1 year of hire