Senior Services Social Worker

Brief Description
The Senior Services Social Worker Position offers a unique opportunity to help build the first PACE (Program of All-Inclusive Care for the Elderly) program in the State of Illinois within the framework of a supportive, innovative, and expert leadership team.

The PACE Social Worker is responsible for planning, organizing, and implementing social work services to LCHC PACE participants and families. This position reports to the LCHC PACE Clinical Services Director.

• Responsible for initial, 6 month, change of condition, and annual assessments
• Presents assessments at care plan conferences with the goal of providing a foundation for development of the Plan of Care and team discussion of participant issues
• Acts as liaison with participant and caregivers regarding orientation to and ongoing relations with interdisciplinary team, day center, and other LCHC PACE, including volunteers
• Provides ongoing support and education to participants and family regarding a variety of issues, including but not limited to the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics, and changing roles
• Works to maintain participant housing through intervention with participant, caregivers, and housing. Will proactively work to partner with participant and/or caregivers to maintain appropriate housing and assist participant to function at most independent community level possible
• Coordinates admissions/discharges to contracted facilities for temporary respite and permanent placement
• Initiates nursing home co-pay status upon charge from team and supervisor when skilled facility placements become permanent
• Performs home visits as needed to assess living environment and support system
• Provides referrals and assessments with contracted personal care boarding homes and assisted living residences
• Facilitate participant move between residences or assisted care facilities if no other family or support systems are present
• Coordinates as needed hospital discharges in communication with attending medical team members
• Initiates referrals to external resources with community agencies such as Adult Protective Services, Housing Authority, or public utility companies
• Assists participants and caregivers to complete POA, Proxy, and DNR directives as needed
• Assists participants and caregivers to set up and maintain personal needs accounts
• Maintains current documentation in participants medical records including initial assessments (narrative, problem lists, assessment forms); reassessments (updated problem lists and chart note); change of status; temporary or permanent placements; hospital discharges; participant staffing’s; home visits; and other significant events
• Assists participants with SSI and SSDI application process as needed.
• Refers potential voluntary disenrollments due to dissatisfaction to PACE leadership team. Completes internal form for disenrollment’s and deaths
• Assists participants and family in coordination with LCHC PACE Outreach Department to keep resources within guidelines for Medicaid eligibility
• Serves as a required member of the Interdisciplinary Team and attends IDT meetings daily.
• Other tasks as assigned

• Commitment to upholding the mission of Lawndale Christian Health Center
• Ability to work independently, take initiative, and set priorities in accordance with the needs and mission of the clinic. Commitment to demonstrating personal integrity through punctuality, honesty, teamwork, attention to detail in all work matters and a willingness learn from others.
• Clear and concise written and verbal communication skills for communicating professionally with patients and coworkers.
• Ability to prioritize and…