Community Social Worker

Community Social Worker

Requirements

• Knowledge of case management theory and practice.
• Knowledge of social services documentation procedures and standards.
• Knowledge of community health services and social services support agencies and networks.
• Knowledge of normative changes (e.g., sensory, cognitive, psychosocial) associated with aging and older adulthood.
• Knowledge of advance care planning and palliative care, and related skill in addressing advance care planning.
• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
• Critical thinking skills required.
• Skill in communication with and psychosocial support of patients with cognitive impairment.
• Skill in psychosocial interventions with challenged caregivers/family systems of high-risk patients.
• Skills in organizing and coordinating.
• Ability to work autonomously is required.
• Ability to monitor, assess and record patients’ progress and make adjustments accordingly.
• Ability to communicate technical information to non-technical personnel with patients and/or their family systems.
• Proficiency in written communication: documentation is clear, concise, accurate, provides meaningful communication and is consistent with ChenMed policy and regulatory requirements.

Responsibilities

• Assists with the management and plan for transitions of care, discharge and post discharge follow up for HPP patients.
• Assess the patients for psychosocial, financial, family issues, palliative care/end of life issues, home safety, etc. that contributed to the hospitalization and/or could contribute to future hospitalizations.
• Assess patients for Medicaid criteria and assist with application process as needed.
• Assessments will be conducted in the center office, by phone call or patient’s home. Could occur in hospital/SNF as needed.
• Collaborates with clinical staff in the development and execution of the plan of care and achievement of goals.
• Supports the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting.
• Coordinates with the case manager, patient and family, support the patient transition to the appropriate/least constrictive level of care assuring needed resources are in place.
• Introduces self to patient/family and explain community social worker role and procedure to contact for needed resources.
• Coordinates obtaining community resources/services that the patient needs and qualifies for as appropriate, e.g., Medicaid, meals, medications, housing, daycare, DME, HHA. etc. If skilled needs or needs for DME are identified, discuss with PCP and make referrals to preferred providers.
• Provides high intensity engagement with patient and family.
• Facilitates patient/family conferences as needed to review goals of treatment, patient personal goals of care, and life planning.
• Enhances a collaborative relationship to maximize the patient’s/family’s ability to make informed decisions.
• Participates in Super Huddles as appropriate.
• Maintains clinical and progress notes for each patient receiving care and provide progress report to PCP and others as appropriate.
• Submits required documentation in a timely manner and in appropriate computer system.
• Provides social services to patients, families, and significant others to enable them to deal with the impact of illness on individual family functioning and to achieve maximum benefits from healthcare services.
• Serves as a patient advocate.
• Other duties as assigned and modified at manager’s discretion.

Preferred Qualifications

• Master’s Degree of Social Work (MSW) preferred.
• A minimum of 2 years’ experience in a primary care setting preferred.
• State Licensure at a Master’s Level is preferred but may be required (dependent on state).