Social Worker - Home Health; FTE

Job Description

0.8 FTE - 8 hour shifts

The Medical Social Worker participates with the interdisciplinary team of primary care physicians, medical director, nurses, physical therapists, speech therapists, occupational therapists, chaplain and volunteer staff. The Medical Social Worker also completes thorough assessments of the patient’s bio-psychosocial situation and provides a vital role in developing a safe and appropriate plan of care. The Medical Social Worker serves as an advocate for the patient and family throughout their entire episodes of care.

Medical Social Workers assist patients applying for disability and/or other financial services while they are under the home health or hospice plan of care. Medical Social Workers focus on goal setting to establish compliance with treatment plans and overcome barriers prohibiting the appropriate level of treatment. The Medical Social Worker helps patients learn how to cope with chronic illnesses, new diagnoses and terminal illness.

The Medical Social Worker assists with providing support, education, and resources for patients and families undergoing chronic or terminal illness. The Medical Social Worker may also assist with goal directed counseling, group intervention, conferences with patients, financial needs assessments, and discharge planning. The Medical Social Worker serves as a community resource liaison providing information and advocacy on the patient's behalf with appropriate local, state, and federal agencies and programs.

• Assist patients and their families with a multitude of complex services during the episode of care including navigating the health care system and systematic levels of resources.
• Provide support for patients and families who are at end of life.
• Collaborate with the interdisciplinary team to provide on-going care planning for patients with complex social/environmental situations including but not limited to:
  • Conducts a comprehensive bio-psychosocial assessment
  • The bio-psychosocial assessment includes: family/support system, education, employment, living arrangements, financial/insurance, significant medical or psychosocial history, and psychosocial treatment plan and goal setting.
  • Assess patient’s family support system, healthcare literacy, current living arrangement, and financial resources.
  • Assess caregivers willingness to assist in the oversight of the patient’s care.
  • Review documentation from the medical record to maintain an understanding of current clinical/medical diagnoses.
  • Review psychosocial history and current mental health diagnoses.
  • Review for barriers that may be preventing the patient from meeting personal and plan of care goals.
  • Conduct on-going assessments to ensure the plan of care reflects the current needs of the patient.
• Participate in the daily interdisciplinary huddles.
• Assessment of the patient and family’s emotional needs, coping skills and level of understanding of chronic or terminal disease process.
• Evaluating and put efforts in place to help strengthen the patient’s family support system
• Provide support and education for patients and families that require or desire additional services to improve health and well-being.
• Provide assistance to connect patient and family with resources in the community
• Informs patients of their right to execute an advanced directive, and explains relevant state laws regarding advanced directives
• Assist with completing advance directives, medical power of attorney worksheets, and POLST Forms. Provide assistance and guidance for families to establish legal guardianship of a patient, deemed incompetent to make their own health care decisions.
• Assisting with adjustment to treatment plans as well as counseling and referrals
• Serve as a liaison between patients and their families to help ensure they understand clinical medical information being provided to them by their primary care physician or specialist.
• Finding community resources for transportation, meals on wheels, respite care and non-emergent transport.
• Assisting patients with maintaining or obtaining insurance, as well as applying for financial aid. This includes interface with the VA, SSI, Medicare, Medicaid…