Senior Social Worker-Home Based Primary Care

Senior Social Worker In Home-Based Primary Care

A senior social worker in home-based primary care plays a central role in supporting older adults and their families by addressing both medical and psychosocial needs. Their work is often collaborative, involving coordination with healthcare providers, caregivers, and community resources. In home-based primary care, the senior social worker's role is to bridge gaps between medical treatment and daily living, ensuring that seniors receive safe, coordinated, and person-centered support in their own homes.

This requires strong communication, empathy, and organizational skills, as well as the ability to adapt to the unique needs of older adults and their families.

Duties and responsibilities include, but are not limited to:

• Evaluate the senior's physical, emotional, social, and financial needs through home visits and interviews.
• Identify strengths, limitations, and risk factors to inform care planning.
• Develop individualized care plans that integrate medical, social, and emotional support.
• Set measurable goals for recovery, independence, and quality of life.
• Connect seniors with home health care, therapy, transportation, and other community resources.
• Liaise with physicians, nurses, therapists, and home care agencies to ensure continuity of care.
• Provide individual and family counseling to address grief, anxiety, depression, or adjustment challenges
• Offer crisis intervention when necessary.
• Educate seniors and families about aging-related issues, available programs, and self-care strategies
• Conduct regular home visits to monitor progress, adjust care plans, and address emerging needs.
• Assist in transitioning seniors from hospitals or rehabilitation centers to home care, ensuring safety and readiness

Work Schedule:

Monday - Friday, 8:00 am - 4:30 pm (

Note:

Work schedules are determined and approved by the supervisor. The incumbent may be required to work various shifts on a permanent or temporary basis based on facility/patient care needs).