Home Care Social Worker (MSW / LMSW)

Hartford Healthcare•East Hartford, CT

1d•Remote

About The Position

The Home Care Social Worker (MSW/LMSW) is a Master's-prepared, licensed or license-eligible clinician who engages patients in their homes to determine their short- and long-term needs and provides short-term interventions to help meet patients' goals of care. The Home Care Social Worker collaborates with patients, their families, physicians, and the home care team to identify and address patients' biopsychosocial needs, barriers to care, risk factors, and other challenges. This role requires experience working with patients who have complex healthcare and psychosocial needs. The Home Care Social Worker works independently, uses critical thinking skills to make accurate and, at times, quick clinical judgments, and responds appropriately to crisis situations.

Requirements

Master's Degree in Social Work.
1-2 years of clinical experience required.
LMSW or LCSW required.
Licensure required within one year of hire.
Considerable knowledge of social, cultural, economic, political, religious, medical, psychological, and legal issues that influence the behaviors of patients and families.
Familiarity with evidence-based assessment tools, including: PHQ-9 / PHQ-2 SLUMS BIMS FAST C-SSRS Caregiver Strain Index
Knowledge of and ability to obtain community resources, including town, state, and federal programs and eligibility requirements.
Proven ability to work effectively both independently and as part of a team.
Ability to adapt to ambiguity and changing processes.
Excellent written and verbal communication skills.
Strong organizational skills and attention to detail.
Strong computer proficiency, including Microsoft Office.

Nice To Haves

Experience in a healthcare setting is strongly preferred.
Bilingual English/Spanish preferred.
Epic experience is a plus.

Responsibilities

Completes comprehensive in-home psychosocial evaluations, including consideration of developmental, social, cultural, substance abuse, psychological, environmental, and medical factors; assessment of physical, social, emotional, and family characteristics; use of evidence-based assessment tools to determine cognitive status and behavioral health needs; evaluation of home safety, family dynamics, caregiver strain, and other risk factors; assessment of the patient and family's understanding of disease processes and treatment options; identification of strengths, available supports, and barriers to care; and determination of the appropriate level of care.
Collaborates with the interdisciplinary team regarding patients identified for Social Work Services and assists in identifying additional patients who may benefit from social work support.
Develops a care plan with measurable goals in collaboration with patients and families, based on a comprehensive, culturally competent assessment.
Implements short-term interventions to address identified barriers and promote health and well-being.
Provides clinical treatment services in the form of triage, crisis intervention, individual and family therapy, screening, and care planning.
Utilizes Motivational Interviewing and coaching techniques to assist patients and families in identifying and achieving goals.
Encourages self-determination and independence by building upon identified strengths.
Serves as an educator for patients, families, the community, and other professionals regarding disease prevention, disease progression, the impact of illness, health maintenance, adherence to treatment regimens, and accessing short- and long-term community resources.
Advocates for the needs and interests of patients to improve access to care and enhance service delivery.
Provides patients and families with resources to support discharge planning and transitions of care.
Maintains timely documentation of social work services that accurately reflects assessment findings, treatment interventions, patient and family needs, social work involvement, and outcomes.
Works collaboratively with primary care and specialty physicians, as well as other members of the healthcare team, to improve quality of life and support patients' goals of care.
Functions as an integral member of the multidisciplinary team.
Participates in case conferences and interdisciplinary team (IDT) meetings.
Assists the healthcare team in understanding social and psychological factors related to patient care.
Acts as a consultant to Agency staff regarding abuse, neglect, exploitation, and community resources.
Identifies Hartford HealthCare at Home and community-based resources appropriate for patients and families.
Performs other duties as assigned.