JOB PURPOSE:

Under the direction of the Social Work Manager, the Social Worker will provide social work services including: advocating, assessing, assisting, collaborating, educating, evaluating, implementing and planning for participants in various aspects of the participant's life including but not limited to psychological, psychosocial, financial, environmental, and interpersonal matters. Social work engagement takes place in various settings including but not limited to the participant's home, PACE site, community settings (hospital, SNF, ALF, etc.).

The Social Worker will serve as a conduit among the participant/authorized representative, the Interdisciplinary Care Team and other community agencies (hospital, SNF, ALF, APS etc.) to ensure the highest level of satisfaction throughout the PACE lifecycle. The Social Worker will provide support to the PACE participant, including but not limited to concrete services, adjustment to illness/disability/treatment, crisis intervention, and end of life care. The Social Worker will assess and evaluate psychosocial functioning; conduct mental status assessments; participate in discharge planning; and enlist collateral community agencies’ services as applicable.

JOB RESPONSIBILITIES:

• Provide ongoing social work services to participants and their authorized representatives to help them understand and follow care delivery recommendations; to assist them with personal and environmental challenges which predispose toward illness or interfere with obtaining maximum benefit from the PACE program.

• Educate participants and their authorized representatives in understanding and using community, health and public services and benefits which help them remain safely in the community (SNAP, SC/DRIE, Medicaid, Medicare, housing, etc.) and assist with making referrals, coordinating services and completing related documents as needed.

• Ensure timely and appropriate communication and coordination of care during/post hospitalization, or other inpatient stay, to ensure that a participant's wishes regarding his/her care are followed during that admission. All communication with facilities, hospital/STR, will be reported to the IDT and documented.

• Ensure telephonic outreach is made within 24-48 hours of hospitalization, and regularly thereafter during admission, to provide support to the participant, to coordinate with the hospital clinical team to discuss participant's treatment plan, and to assist in discharge plan coordination with the PACE IDT. The Social Worker will also conduct a visit to the participant within 72 hours of discharge (business days) to assess for any psychosocial issues that may contribute to re-hospitalization.

• Provide social work consultation to participants and authorized representatives as indicated. Provide education on treatment options, including palliative and end of life care, and help coordinate services. Arrange bereavement assistance, supportive counseling, or other behavioral health services as needed. Provide caregiver support as needed.

• Complete biopsychosocial assessments (semi-annual, quarterly revisit, PRN, SOC, ROC, SCIC, SDR), cognitive/emotional status assessments (i.e. GDS, SPMSQ) and other assessments as applicable. Complete HCP document and facilitate completion of advance directives, such as the DNR/DNI/DNH/MOLST documents.

• Assure participant-focused Care Plan psychosocial goals and interventions are applied.

• Utilize EMR for completion of assessments and other systems as needed.

• Ensure documentation is completed timely (within 24-72 hours) and accurately.

• Organize and manage workload to ensure provision of appropriate and maximized social services to participants and authorized representatives. Use case management and clinical skills to help participants and families address and resolve social, financial, and psychological problems related to the participant's health. Ensure timely and appropriate coordination and follow-through of care and services.

• Responsible for integrating best practices into the participant’s total care by collaborating with other professional personnel within CenterLight Healthcare, in acute care institutions, skilled nursing facilities, and other community agencies.

• Facilitate psycho-educational presentations for the participants in the day health centers. Presentations will be for educational purposes and to promote the social worker’s role in the IDT.

• Attend and actively participate in IDT and care plan meetings. Identify, document as part of the care plan and present social work-related concerns and/or issues and appropriate social work interventions and recommendations. Ensure social work interventions are applied and participant-centered goals are met.

• Participate in appropriate continuing education and professional training programs sponsored internally by CenterLight Healthcare and/or applicable outside agencies. Participate in staff enhancement through professional knowledge by attending approved seminars/workshops relevant to the field of Social Work.

• Participate in peer supervision conferences and individual conferences with the Social Work Manager/designee.

• Represent the Social Work department and CenterLight Healthcare at appropriate meeting and conferences in the community.

• Only act within the scope of the individual’s authority to practice.

• Meet a standardized set of competencies for the specific position description established by the PACE organization before working independently.

• All other duties as assigned by supervisor.

Schedule: 9:00AM – 5:00PM

Weekly Hours: 35

QUALIFICATIONS:

Education: M.S.W. from an accredited college or university.

Experience:

• One (1) year experience in a health care setting.

• Minimum of one (1) year of experience working with a frail or elderly population or, if the individual has less than one (1) year of experience but meets all other requirements, must receive appropriate training from the PACE organization on working with a frail or elderly population upon hiring.

• Experience in home care and/or field work is preferred.

• Regular access to a car for field visits is preferred but not required.

License: LMSW or LCSW required. Must have active NY State Social Work license.

Additional Requirements:

• Be legally authorized (for example, currently licensed, registered, or certified if applicable) to practice in the State in which the healthcare professional will perform the function.

• Be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact.

Physical Requirements

Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to:

• Standing – Duration of up to 6 hours a day.

• Sitting/Stationary positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.

• Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and ability to lift patients safely and using OSHA guidelines, etc.

• Bending/Squatting – Must be able to safely bend or squat to care for patients, use medical supplies, etc.

• Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas Position requires the individual to be able to travel, and walk between sites/locations and work areas throughout the day.

• Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools (ie. typing, use of medical supplies, equipment, etc.)

• Sight/Visual Requirements – Must be able to visually assess patients, read orders type/write documentation, etc. with accuracy.

• Audio Hearing and Motor Skills (language) Requirements – Must be able to listen attentively and document information from patients, community members, providers, etc., and intake information through audio processing with accuracy. In addition, must be able to speak comfortably and clearly with language motor skills for customers to understand the individual.

• Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.

  We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities.

Salary Range (Min-Max):$66,412.66 - $90,720.88

Note: Position's wages are contingent upon terms and conditions outlined in the collective bargaining agreement.

CenterLight Healthcare is one of the oldest non-profit comprehensive healthcare organizations in the United States. We are a premier provider of home and community-based healthcare and services in the New York metropolitan area, serving all five boroughs of New York City, as well as Westchester, Nassau and Suffolk Counties.

Through CenterLight TeamCare, we offer comprehensive healthcare and other services that enrich the lives of our participants and let them live safely at home and in their communities. TeamCare, a program of CenterLight Healthcare, is the nation’s largest not-for-profit Program of All-Inclusive Care for the Elderly (PACE). Each day, our employees serve a richly diverse population of 3,300 participants, speaking 75 languages and dialects throughout our 14 facilities. Learn more at www.centerlightteamcare.org.

Need help creating an account? Contact CenterLight HR Helpline 347-640-6108.