PACE Master's Level Social Worker

Valir Health•Shawnee, OK

12d•Onsite

About The Position

Valir PACE provides integrated medical and social services to seniors. The Master's Level Social Worker coordinates transitions of care and participants’ mental and psychosocial care, provides case management, and counsels participants on financial and advanced care planning options, including advance directives and DNR orders. The role advocates for participants and works to ensure their wishes are honored. The social worker coordinates care with participants, families, the PACE interdisciplinary team, external providers, pharmacies, and transportation services. The position also connects participants and families with community resources, supports caregivers, conducts assessments, and facilitates care-planning and family meetings.

Responsibilities

Serve as the primary point of contact for transitions of care.
Arrange beds for appropriate levels of care, including acute, post-acute, and hospice care, and coordinate necessary PACE interdisciplinary team members and external providers, pharmacy, and transportation.
Identify and obtain access to community resources for participants and their families.
Organize caregiver and other appropriate support groups and identify resources to address participants’ psychosocial needs.
Provide case management services to patients.
Assist participants and families with DNR orders and advance directives, ensuring directives are congruent with the participant’s disease process.
Support participants in developing a clear end-of-life plan, communicating it to family and the care team, and aligning it with the participant’s wishes.
Perform annual, bi-annual, and status-change assessments as required by federal and state regulations.
Conduct routine mental health assessments, including assessments for depression, anxiety, and caregiver burnout, and make appropriate referrals for mental health services and caregiver support.
Provide and recommend group counseling to support participants’ mental health hygiene and coping skills.
Facilitate care-planning meetings, family meetings, and meetings with other care teams, such as nursing home teams.
Provide escort services to participant appointments when needed to advocate for participants.
Perform other duties and responsibilities as assigned.