Social Worker

Provides comprehensive social work services to SNF residents / clients. This includes, but is not limited to psychosocial evaluation, assessment for admission, patient's rights and advocacy, and social casework, group work and family counseling as appropriate.

Key member of the interdisciplinary care team. Ensures maximum quality of life for assigned residents / clients.

Responsibilities

• Provides social work interventions for residents and families in time of crisis, deteriorating health (physical and mental), dealing with disabilities, deterioration of independence and end of life, etc.
• Educates resident or client and family / care giver on advanced directives.
• Serves as advocate for resident / client in absence of caregiver / family or if resident is unable to do so.
• Responsible for discharge planning. Coordinates identified resources and services for timely discharge, involving the resident and family.

Ensures complete, accurate and timely documentation.

• Coordinate / facilitate initial, annual and prn resident and family meetings. Ensures communication with family members not in attendance.
• Provides effective orientation for new residents / clients and families / care givers. Reviews resident's rights.
• Assesses resident financial situation, referring to Finance Department as necessary, i.e. Medicaid application. Provides financial counseling as required.
• Reviews significant events / occurrences related to family, finance, and psychosocial behavioral changes with interdisciplinary team.
• Actively participates as member of interdisciplinary team, sharing psychosocial information and contributing to development of resident care plan.

Makes suggestions for interventions and recommendations for revised treatment plans to address social work concerns and issues.

• Maintains communication with other team members to discuss progress and coordinates resident care efforts.
• Assesses the resident and family's adjustment to placement and environment. Provides intervention as required.
• Provides timely social work services following departmental policies, procedures and protocols as well as regulatory guidelines.
• Complies with all third party regulations. Keeps current in knowledge of changes to regulations and best practices in social work.
• Maintains current advance directives and updates quarterly, upon return from hospital, and / or prn.
• Maintains accurate, complete, and timely, psychological assessments, care plans (initially, quarterly, annually, significant change).
• Maintains accurate, complete and timely Social Work documentation.
• Maintains current family contact information, updating annually and prn.
• Counsels and instruct paraprofessional staff in psychosocial and communications issues and assists with difficult family / care-giver conflicts.
• Attends conferences / in-services as requested and educates social work staff on learnings.
• Educates other team members regarding community resources, Medicaid and other social programs and psychosocial issues related to client care.
• May supervise BSW and MSW students as appropriate.
• Maintains current knowledge of community resources and new applicable regulations.
• Actively participates in Quality Assurance Performance Improvement (QAPI) initiatives. Analyzes QA indicators and initiates remedial action as required.

Maintains threshold of errors below target level.

• Monitors incident reports for indications of care plan modifications and required interventions. Initiates actions as appropriate.
• Monitors / assesses resident, family and resident's environment for areas where social work planning and interventions can be of assistance.

Qualifications

• Bachelor’s degree in Social Work, Human Services, Sociology, Special Education, Rehabilitation Counseling or Psychology.
• Minimum of one year experience with geriatric care, long-term health care, or community services to the aging, in a direct service capacity.
• Proven assessment skills.
• Demonstrated ability to work in a team setting.
• Knowledge of regulatory requirements of DOH and all pertinent agencies.
• Outstanding interpersonal skills and the ability to communicate effectively with clients, residents, and families from diverse backgrounds who may have physical, sensory and mental impairments.
• Proficient in MS Office and able to learn new software rapidly.

An equivalent combination of education and experience which provides proficiency in the areas of responsibility listed above may be substituted for the above education and experience requirements.

Physical Requirements

Walking 20.0%

Standing 30.00%

Sitting 30.00%

Lifting 10.00% Nominal