Proposed Schedule: 40 hours per week. Monday-Friday 8am-4:30pm

Summary:

The Program of All-Inclusive Care for the Elderly (PACE) is a community-based program that provides coordinated medical and social services to eligible older adults who want to continue living in their own home despite chronic care needs. The Social Worker under direct oversight of the Clinical Leader, is an integral member of the PACE at Hudson Headwaters (PHH) Interdisciplinary Team (IDT). The Social Worker is responsible for screening, psychosocial assessment, care plan implementation and appropriate interventions including but not limited to patient rights and advocacy functions, daily care management, individual/group and family counseling as appropriate, referrals and education for all Participants.

Essential Duties and Responsibilities:

• Perform initial assessment of potential Participants; develop a treatment plan in collaboration with Participant, family, and team members; perform semiannual and annual assessments and develop individualized care plans; attend intake and assessment meetings, and Participant and family/caregiver conferences as appropriate.
• Participate in the development and revision of the Participants’ plan of care as an IDT team member; integrate the social work treatment plan into the overall plan of care developed by the IDT. Assess the Participant, family, and home environment for areas where social work planning and interventions can be of assistance; maintain required documentation in the EMR (Electronic Medical Record) regarding Participants’ care and progress within the specified timeframe.
• Assist in determining Participant and family needs related to social supports, psychological supports, financial supports and/or counseling as well as housing options/alternatives. Collaborate with the Participant and family in making necessary applications for public assistance, housing placement, pre-admission screening, etc.
• Confer with the Participant and family (as appropriate) regarding individual expectations plus long- and short-term goals; attend/coordinate family meetings; attend nursing home care planning meetings, hospital discharges, etc. as appropriate.
• Attend and actively participate in morning IDT meetings; review significant events/occurrences as related to family, finance, social determinants, and psychosocial/behavioral changes with IDT; make recommendations for appropriate interventions/care plan changes.
• Intervene in crisis; attend to the emergency needs of the Participant and/or family relating to illness, disability, deterioration of independence, etc.; advocate Participants’ needs, wishes and right to self-determination.
• Maintain active communication with other team members and outside contracted providers to discuss progress and coordination of Participant care efforts.
• Educate other team members regarding community resources and social programs available; maintain current knowledge of community resources and new applicable regulations.
• Counsel and provide education to staff in psychosocial and communication issues and assist with difficult family/care-giver conflicts.
• Demonstrate adherence to all compliance policies and procedures; responsible for promoting and fostering compliance in the workplace.
• Ensure the highest quality of care by performing responsibilities according to the highest professional standards.
• Attends staff meetings.
• Other duties as assigned.

The requirements listed below are representative of the knowledge, skill, and ability to perform the essential functions:

• Graduate of an accredited college with a Master of Social Work degree
• Current NYS license and certification as a Licensed Master of Social Work
• Minimum (1) year post MSW experience
• Minimum (1) year care management experience
• Have 1 year of experience working with a frail or elderly population or be willing to receive appropriate training upon hire
• Must possess a valid driver’s license
• BLS certified or willing to complete necessary certification
• Experience or ability in working with a diverse population
• Experience working within the framework of an interdisciplinary team
• Excellent interpersonal skills including ability to work cooperatively on an interdisciplinary team
• Highly organized, able to prioritize tasks, and conduct thorough follow-up
• Excellent written and verbal communication skills.
• Proficient computer competencies including Microsoft application and the ability to navigate Electronic Health Record platforms
• Must be able to work independently as well as collaborate and communicate effectively with colleagues, supervisors, service delivery partners, other health care professionals and co-workers to build and maintain effective dynamic professional team relationships.

The pay range for this position is $60,000 - $69,000 annually and will be determined based on skills and experience.