SUMMARY: Works in conjunction with EHMG clinical staff to evaluate the psychosocial and functional needs of at risk/high risk residents providing referral or counseling, case management as necessary.
ESSENTIAL DUTIES AND RESPONSIBILITIES: include the following. Other duties may be assigned.
1. Follow residents that are identified by Resident Services Coordinator II (RSC II), Medical Provider, Administration, or other members of IDT team that require transition to higher level of care.
2. Provide ongoing comprehensive Social Worker (SW) interventions and oversight for residents on caseload which may include coordination of increased services, ongoing case management, regular family and resident contact, facilitation of family and team meetings. Once resident’s needs are stabilized or transitioned to another care setting, SW involvement is terminated.
3. Provide problem solving for complex resident situations and informal consultation on person centered/ holistic responses for problematic situations encountered within other departments: administration, dining services, communications specialists/ security, general services, etc.
4. Identifies cases which may require additional outpatient case management oversight, refers out and collaborates with that case manager as appropriate.
5. Attends regular rounds meetings with Medical Providers to review residents currently followed by SW and those that may now be in need of SW support.
6. Is available for intervention/ meetings on as needed basis during Medical Provider/ Patient meetings.
7. Participate in Resident review and Resident Transitions IDT meetings.
8. Provide crisis intervention with residents who have high level needs, need to transition to higher level of care for respite or rehab stay on as needed basis.
9. Provide Counseling Services to residents who desire or who are referred by Medical Provider.
10. Complete formal assessments for residents as needed i.e. - MoCa, VES 13, GDS, other.
11. Participates with other team member in the education of residents about the importance of Advance Directives, Do Not Resuscitate and Financial Power of attorney documents.
12. As needed, follow residents returning to IL from rehab or hospital stay.
13. Maintains records on all residents served and documents activity as appropriate in the EMR.
14. Maintains confidentiality of resident information.
15. Develops referral network within the community for available services, and makes appropriate referrals to and consults with other professional services as indicated.
16. Continues to enhance professional skills through continuing education, community in-services, leadership training and other professional activity. Shares knowledge gained from training and educational sessions.
KNOWLEDGE, SKILLS AND ABILITIES:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Excellent interpersonal skills.
• Excellent written, verbal and listening skills.
• Ability to work independently, implements plans, and has excellent problem solving skills.
EDUCATION and/or EXPERIENCE:
• Social Work degree (BSW or MSW) required.
• Clinically Licensed Social Work – highest licensure in the state- required.
• Minimum of three years of social work experience is required. (In a health care setting preferred).
• Knowledge of geriatric population, case management and dementia preferred.
Must be able to read, write and communicate in the English language.
LICENSES, CERTIFICATES, REGISTRATIONS:
Highest state level Clinical Social Work licensure and/or certification as required by State Board.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to stand and walk. The employee frequently is required to use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee is occasionally required to stoop, kneel, crouch, or crawl. The employee lift and/or move up to 25 pounds. Able to transport a resident in a wheelchair. Specific vision abilities required by this job include close vision, distance vision, and depth perception. Keyboard repetitive motion.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
General office environment as well as residential apartments.
May be required to walk long distances.
ROUTINE DECISION MAKING:
• Works in collaboration with the Medical Director and other interdisciplinary team members to support residents requested services.
FORMAL POLICY-SETTING RESPONSIBILITIES:
• Provides input into policies.