Licensed MSW, PRN

Ensures quality delivery of social worker services and assists in providing home health care services that reflect the Agency’s philosophy and standards of home health care.

• Assists in evaluating referrals for admission to the home health program:
  • Assists in identifying patients who would benefit from services.
  • Acts as a resource person to hospital social service departments, nursing personnel, and discharge planners to evaluate referrals as appropriate.
  • Assists in investigating the patient’s financial situation as appropriate.
• Assists in identifying patients’ needs and in formulating an initial plan of care for those patients admitted into the Agency’s service.
  • Assesses the patient, his/her family, support system, and home situation, and identifies needs or potential needs.
  • Works with the nurses or other health team members and formulates a comprehensive plan of care to meet the patients’ needs.
• Explores available community resources that might be helpful in meeting the patients’ needs.
  • Explores available community resources and assists patient in qualifying for eligible programs.
  • Assists patients in utilizing any resources that are available to obtain maximum benefit from the program.
  • Follows up Adult Protective Services referrals with letters to the Department of Social Services directors.

• Counsels and supports patients.
  • Assists patients in utilizing or building support systems.
  • Assists patients and their families in dealing with the emotional aspects of their illnesses and conditions.
  • Assists patients and their families in accepting their medical condition and complying with medical recommendations.
  • Provides assistance to patients in formulating Advance Directives.

• Participates in multi-disciplinary team meetings.
  • Reevaluates goals and plans of care and offers suggestions to meet patients’ needs in a better way.
  • Assists health team members with emotional factors related to patients’ health problems.
  • Acts as a resource person for health team members in planning patient care and offers suggestions as appropriate.

• Maintains required medical records.
  • Documents observations made, and actions taken in a timely fashion using paper or electronic means.
  • Documents patients’ progress or response to care as appropriate using paper or electronic means.

• Keeps physicians informed of patients’ progress.
  • Forwards appropriate documentation concerning patients’ progress and summary of care to physicians at regular intervals.
  • Discussed patients with physicians when appropriate to clarify goals and objectives and to clarify the plan of care.

• Performs other duties as assigned by management.

• Holds Master’s degree from school of social work accredited by the Council on Social Work Education.
• Has minimum of one-year experience as a social worker in a hospital, out-patient, nursing home, or home care setting.
• Has a thorough knowledge of community resources.
• Has good communication skills.
• Is able to deal effectively with stress.