PACE KC Social Worker

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The Social Worker contributes the psychosocial perspective to the interdisciplinary evaluation, assessment, plan of care, ongoing services and disenrollment process that occur once prospective participants begin the intake process and continue with enrollment and ongoing services. Routinely assesses the needs of participants and families and determines the most appropriate and effective social services interventions to meet participant goals. Based on the assessment and/or evaluation of the participant, the Social Worker works in coordination with the IDT, Behavioral Health Specialist, contracted providers, and others to implement the plan of care and to provide psych/social interventions.

The Social Worker acts as an education resource for the PACE team and supports the organizations goal to provide high-quality, person-centered care to all participants.

The Social Worker contributes the psychosocial perspective to the interdisciplinary evaluation, assessment, plan of care, ongoing services and disenrollment process that occur once prospective participants begin the intake process and continue with enrollment and ongoing services. Routinely assesses the needs of participants and families and determines the most appropriate and effective social services interventions to meet participant goals. Based on the assessment and/or evaluation of the participant, the Social Worker works in coordination with the IDT, Behavioral Health Specialist, contracted providers, and others to implement the plan of care and to provide psych/social interventions.

The Social Worker acts as an education resource for the PACE team and supports the organizations goal to provide high-quality, person-centered care to all participants.

• Acts as an engaged member of the Interdisciplinary Team (IDT). Regularly attends meetings and provides meaningful input.
• Performs in-person initial assessments for enrolling participants to obtain a complete psychosocial history, which may include descriptions of cognitive status, social supports, family dynamics, mental health and substance dependency and other issues and needs. Coordinates with the IDT to develop a comprehensive plan of care for each participant.
• Reassesses participants on a semi-annual and as-needed basis and coordinates with the IDT to update the plan of care for each participant.
• Responsible for the psychosocial well‑being of participants in coordination with the IDT. 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, PACE model and PACE health services.
• Identifies, provides and/or coordinates for the medically‑related social, psychological and spiritual needs of the participants. Implements social work interventions, case management, or psychosocial support.
• Support the IDT with acute and complex case management.
• Acts as facilitator for meetings with participant, family, caregivers, and community agencies to clarify, or problem‑solve issues regarding the plan of care. Mediates discussions between all parties.
• If hospice care is appropriate, actively provides emotional support, grief work, education and funeral/financial planning referral. Facilitates hospice or nursing home placement as needed. Initiates referrals to external resources with community agencies such as Adult Protective Services, housing resuscitate (DNR) directives as needed.
• Acts as an educational resource to other team members, participants, families, and others regarding topics such as dementia, difficult behaviors, self‑determination, validation, and person-centered care.
• Engages in coordination with outside agencies such as Adult Protective Services, Ombudsman, contracted providers and facilities, etc. in coordination of care and/or on behalf of the participant.
• Identifies opportunities for quality improvement and engages organizational mechanisms as needed.
• In coordination with the Center Director and other members of the Social Work Department, may design, implement, and/or facilitate participant and/or family support groups.
• Performs other duties as assigned.

• Masters degree Social Work.
• Licensed Master Social Worker (LMSW) preferred.
• Minimum of 2 year experience working with the elderly population as a MSW.
• Knowledge of psychosocial issues of the chronically ill and their caregivers.
• Knowledge of providing group and individualized recreational therapy to maintain participant maximum independence and function.
• Maintain accurate records and prepare clear and concise reports, correspondence, and other written documentation.
• Current driver’s license, auto insurance, and dependable transportation.

• Effective oral and written communication.
• Strong interpersonal skills with ability to build relationships.
• Effective…