Social Worker-PACE (Murrieta)

Social Worker-PACE (Murrieta)

Community health is about more than just vaccines and checkups. It's about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We're with you every step of the way, with the care you need for each of life's chapters. At Neighborhood, we are Better Together.

Neighborhood Healthcare PACE is a managed medical plan built around surrounding participants with a team of physicians, nurses, social workers, therapists and care coordinators to help them maintain good health and a good quality of life. Our goal is to keep our seniors happy and healthy at home surrounded by their family and community.

As a private, non-profit 501(C) (3) community health organization, we serve over 500k medical, dental, and behavioral health visits from more than 100,000 people annually. With two PACE centers located in Riverside County, our PACE program is positioned to serve over 650 senior participants.

The Social Worker will manage a caseload of participants by providing a psychosocial perspective to the interdisciplinary evaluation, assessment, plan of care, ongoing services, and disenrollment processes of the PACE program at Neighborhood Healthcare. This role will collaborate with the interdisciplinary team to optimize the health status and quality of life of Neighborhood PACE participants. Additionally, this role will liaise between participants, members of participants' support network, and the interdisciplinary team.

Schedule:

M-F 8am-5pm. This position is fully onsite.

Responsibilities

• Works with the PACE Interdisciplinary Team (IDT) to conduct initial, semi-annual, unscheduled, and annual assessments
• Provides participant health status updates to appropriate staff in daily meetings
• Obtains extensive psychosocial history from participants and/or family members upon admission to program and intermittently at pre-enrollment
• Coordinates, schedules, and facilitates family conferences in conjunction with the PACE IDT to address levels of care, medication/treatment non-compliance, out-of-home placement, complex diagnoses, behavioral concerns and contracts, conditions of involuntary disenrollment, and alternative program options
• Develops and facilitates various group counseling topics designed to assist at-risk populations over the age of 55 with chronic health conditions
• Provides individual caregiver and family support counseling, as needed
• Coordinates with participants, family/caregivers, and primary care providers to complete advance life planning documents, assist with end-of-life planning, and provide educational resources
• Conducts independent risk and safety assessments at skilled nursing facilities, residential care facilities for the elderly, assisted living facilities with/without memory care units, hospitals, and in-home, as needed
• Screens and develops share of cost for out-of-home placements based on financial documentation from participants and family members
• Creates and executes supportive housing forms with care facilities and family members
• Conducts intermittent and annual income reviews to update supportive housing forms and share of costs
• Schedules, coordinates, and accompanies participants and family members with transportation and admission to higher level of care to promote safety and continuity of care in cases of high acuity
• Implements hospice and palliative care services by providing referral documentation, coordination, education, and support to participants and families
• Communicates with hospitals/skilled nursing facilities and utilizes external medical records systems to coordinate tailored discharge planning for participants
• Assists with ongoing financial eligibility for participants, including Medi-Cal recertifications, as needed
• Liaises effective connections and communications with other organizations in the eldercare field
• Provides support and education to staff members in areas of social, emotional, and cultural factors in the participant population, including how these factors relate to health, medical care, and the availability of social services in the community
• Schedules, coordinates, and conducts in-home visits and assessments independently and in conjunction with the PACE IDT, as needed
• Provides redirection and support for participants with behavioral needs during PACE Day Center attendance, utilization of PACE transportation, and use of other PACE services
• Refers participants and families to appropriate community agencies and facilities while acting as an advocate and liaison with such organizations
• Conducts discharge planning to promote continuity of care in the event of disenrollment
• Maintains federally compliant and timely documentation of institutionalizations, Adult Protection Service reports/follow-ups and consultations, community contacts, family conferences, assessments, and other case management notes in medical records
• Attends required staff meetings/trainings and voluntary professional…