Social Worker - Primary Care

Social Worker - Primary Care At Home

The Licensed Social Worker
- Home-Based Services will provide services to adult and geriatric homebound patients in their residences and via telehealth. This role requires travel to patient homes and the ability to work effectively in a home-based care setting.

The Social Worker reflects the mission, vision, and values of NM, adheres to the organization's Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.

Responsibilities:

• Provide social work services to adult and geriatric patients in their residences and via telehealth.
• Travel to patient homes to deliver services.
• Work in patient residences, which may include private homes, group homes, or assisted living facilities, and adapt to a variety of environmental conditions commonly encountered in the home setting, including pets, pet dander, dust, smoke, noise, clutter, varying indoor temperatures, and weather conditions during travel.
• Maintain effective communication and coordination with patients, families, and care teams.
• Ensure services are provided in accordance with professional standards and organizational requirements.
• Collaborates and participates in the coordination of screening, assessment, and discharge planning activities in high risk patients and their families with complex psychosocial and economic needs.
• Utilizes expertise and problem solving skills to achieve optimal clinical outcomes within effective resources and time frames.
• Promotes a seamless and safe discharge throughout the continuum of care
• Collaborates with the care team for discharge planning and community linkage for patients and families with complex social, economic, and emotional needs.
• Participates in care conferences and unit rounds. Keeps all members of the care team apprised of the current state and plan of care.
• Develops positive relationships with co-workers, members of the care team, and community resources.
• Collaborates with care team members to identify at risk populations and opportunities to improve care delivery and on-going support, thus increasing efficiencies and effectiveness.
• Makes timely and appropriate referrals to ancillary support staff in order to facilitate progress toward a safe discharge.
• Partners with the post-acute care providers and shares appropriate and pertinent information in order to create a seamless and safe discharge plan.
• Identifies, assesses and responds to patient and family needs, incorporating age specific developmental, psychological, cultural and spiritual needs. Emphasis is placed on addressing the social and emotional needs of the patient and family that may impact on the patient's response to medical treatment. These needs may include, but are not limited to, adjustment to illness, poor or limited coping abilities, functional impairment, mental illness, guardianship issues, compliance, need for additional resources due to limited funds available, substance abuse, cultural differences, death, dying, bereavement, and family welfare, including abuse, neglect, and domestic violence.
  
  Adoptions in the mother/ baby area.
• Provides timely and effective interventions for patients and families in emergency and crisis, including referrals to appropriate support resources.
• Educates team members regarding the socio-economic, emotional and cultural issues that impact care delivery, coping skills, and response to treatment.
• Serves as an advocate for the patient and family. Serves as a lead resource and assists with referrals in coordinating charity and financial resources, guardianship issues, family problems or conflicts, and competency issues.
• Assists with the maintenance of information and referral lists relative to post-acute care resources.
• Administers and interprets tests and measures of psychosocial functioning for the purpose of diagnosing mental, emotional, behavioral, addictive, and development disorders and disabilities.
• Develops and implements appropriate assessment- based treatment plan. Consults with team managers, statutory and voluntary agencies and patient's relatives to ensure compliance…