The Home Care Social Worker assists in developing a plan, which meets the psycho-social needs of the patient and family. This position assists the patient, family, and home care staff in identifying and utilizing available services and resources. WHO WE ARE With 12 ministries and access points across Indiana and Illinois, Franciscan Health is one of the largest Catholic health care systems in the Midwest. Franciscan Health takes pride in hiring coworkers that provide compassionate, comprehensive care for our patients and the communities we serve. WHAT YOU CAN EXPECT Completes initial and ongoing assessments, which include the psychosocial, financial, cultural and emotional patient environment. Determines social, psychological, cultural and financial situations and the impact on the patient's plan. Initiates discharge planning with the patient and appropriate others. Consults with physicians, nurses, case managers and other disciplines regarding patient's progress and any patient issues. Evaluates the patient's progress and updates the plan of care with the patient and caregiver on a regular basis. Establishes a plan of care/service that is realistic and has measurable goals, working with the patient, caregivers, and patient's family. Documents patient assessments and pertinent information in a timely manner. Collaborates with patient and other healthcare personnel or outside agencies regarding coordination of care.