Social Worker Lead

On Lok PACE

We are a non-profit committed to our participants.

We are a non-profit committed to our participants.

PACE (Program of All-Inclusive Care for the Elderly) was developed to answer the many problems around caring for frail seniors. The PACE model is centered on the belief that it is better for the well-being of seniors with chronic care needs and their families to be served in their community whenever possible.

Seniors, their family members, and caregivers face many issues, including transportation to appointments, management of medications, coordination of medical care from different specialists, lack of social interaction, and ability to stay alone  Lok PACE participants receive in home care services and transportation to a On Lok PACE center for primary medical care, social and recreational activities, and other senior care services.

We understand the importance of a system that works together. Your expertise, drive and passion can help us carry out our mission to improve lives and advance healthcare.

POSITION SUMMARY:

The Social Work Lead (SWL) provides direct case management services to On Lok participants and as acts as the subject matter expert (SME) providing department leadership including administration, mentorship, and consultation at an appointed center. The primary role of the SWL is to assist participants and their family/caregivers to cope with the social and emotional issues and practical arrangements related to maintaining their independence.

With oversight from the Regional Social Work Manager and the Program Manager, the SWL serves as an integral member of the Interdisciplinary (IDT) team providing assessments, coordination, treatment planning, information and referral to community resources and other social work services to meet the complex needs of participants and their families.

• Utilize independent judgement and discretion to provide case management to a panel of participants
• Conduct initial and routine psychosocial assessments on new and existing participants in order to develop, implement and update individualized care plans and interventions.
• Partner with caregivers and support system to develop care plan and deliver services.
• Identify risks and other psychosocial problems.
• Identify service needs of each participant, advocate, refer, coordinate and follow up in a timely fashion.
• Provide individual counseling.
• Facilitate family conferences.
• Reach out to the larger community to meet participants' specific needs. Act as the main liaison between participants, caregivers, the team, and the community.
• Assess needs and complete discharge planning when a participant dis-enrolls from On Lok.
• Facilitate participant and/or caregiver groups and participate in special events such as weekend caregiver workshops.

• Act as the main liaison between participants, caregivers, the team, and the community.
• Work with relevant departments such as Health Plan and other community agencies e.g. RCFE, NF, DAAS (Department of Adult and Aging Services).
• Adhere to all ethical and legal standards of social work practices.
• Comply with all On Lok policies & procedures including but not limited to PACE, safety, and confidentiality requirements.
• Fulfill all documentation requirements in a timely and accurate manner.
• Actively participate in team meetings, advocate for the needs of participants and their caregivers, compromise differences among team members, support and carry out team plans.
• Incorporate the Healthcare Hospitality G.R.E.A.T. Practices for 5-Star service.
• All other reasonably related duties as assigned

• Is the subject matter expert (SME) of the electronic health record for the social work department.
• Assist in the review and update of department and IDT policies and procedures.
• Assist in the orientation and training for new Social Workers and Social Work Aides.
• Assist in overseeing competencies for social workers.
• Assist in developing, maintaining and facilitating relationships with other clinical disciplines and non-clinical staff in order to deliver quality participant care at appointed center.
• Assist with developing the social work education program.
• Primary point-person for social work issues at appointed center.
• Assist in providing support to Social Workers at appointed center.
• Assist in the continuous quality improvement of social work services and efficiency of systems.
• Actively participates and contributes to the Social Work Leadership Council (SWLC) activities.
• Assist with developing the social work continuing education program.
• Is the primary point-person for social work issues at the appointed center.
• Contribute additional clinical and/or workflow process perspective regarding participant care to Program Manager in support of the MSW and SWA, as requested.
• Assist in coordinating student…