Social Worker - Primary Care At Home

Responsibilities

• Provide social work services to adult and geriatric patients in their residences and via telehealth.
• Travel to patient homes to deliver services.
• Work in patient residences, which may include private homes, group homes, or assisted living facilities, and adapt to a variety of environmental conditions commonly encountered in the home setting, including pets, pet dander, dust, smoke, noise, clutter, varying indoor temperatures, and weather conditions during travel.
• Maintain effective communication and coordination with patients, families, and care teams.
• Ensure services are provided in accordance with professional standards and organizational requirements.
• Collaborate and participate in the coordination of screening, assessment, and discharge planning activities in high risk patients and their families with complex psychosocial and economic needs.
• Utilize expertise and problem-solving skills to achieve optimal clinical outcomes within effective resources and timeframes.
• Promote a seamless and safe discharge throughout the continuum of care.
• Collaborate with the care team for discharge planning and community linkage for patients and families with complex social, economic, and emotional needs.
• Participate in care conferences and unit rounds.
• Keep all members of the care team apprised of the current state and plan of care.
• Develop positive relationships with co-workers, members of the care team, and community resources.
• Collaborate with care team members to identify at-risk populations and opportunities to improve care delivery and ongoing support, thus increasing efficiencies and effectiveness.
• Makes timely and appropriate referrals to ancillary support staff in order to facilitate progress toward a safe discharge.
• Partners with the post-acute care providers and shares appropriate and pertinent information in order to create a seamless and safe discharge plan.
• Identifies, assesses, and responds to patient and family needs, incorporating age-specific developmental, psychological, cultural, and spiritual needs. Emphasis is placed on addressing the social and emotional needs of the patient and family that may impact on the patient's response to medical treatment.
• Provides timely and effective interventions for patients and families in emergency and crisis situations, including referrals to appropriate support resources.
• Educates team members regarding the socio-economic, emotional, and cultural issues that impact care delivery, coping skills, and response to treatment.
• Serves as an advocate for the patient and family.
• Serves as a lead resource and assists with referrals in coordinating charity and financial resources, guardianship issues, family problems or conflicts, and competency issues.
• Affords assistance with the maintenance of information and referral lists relative to post-acute care resources.
• Administers and interprets tests and measures of psychosocial functioning for the purpose of diagnosing mental, emotional, behavioral, addictive, and developmental disorders and disabilities.
• Develops and implements appropriate assessment-based treatment plans.
• Consults with team managers, statutory and voluntary agencies, and patient’s relatives to ensure compliance with treatment plans.
• Provides crisis-oriented psychotherapy and connects patient and family with the appropriate resources.
• Supervises and trains lower-level social workers, students, or interns.
• Applies specialized clinical knowledge and advanced clinical skills in the areas of assessment, diagnosis, and treatment of mental, behavioral, addictive disorders or conditions and makes appropriate referrals or transfers to the correct level of care.

Qualifications

Preferred qualifications include:

• Master’s degree in Social Work from an accredited college or university.
• License to practice Social Work in the State of Illinois.
• Experience working with adult and geriatric patients in home-based care settings.
• Experience with telehealth services.
• Experience with crisis intervention and emergency management.
• Experience with discharge planning and community linkage.
• Experience with post-acute care resources.
• Experience with psychosocial assessments and interventions.
• Experience with crisis-oriented psychotherapy.
• Experience with supervision and training of social workers.
• Experience with specialized clinical knowledge and advanced clinical skills in the areas of assessment, diagnosis, and treatment of mental, behavioral, addictive disorders or conditions.