Social Work Care Manager-MSW

EveryAge•Lexington, NC

About The Position

Under the supervision of the Center Administrator, plans, organizes and implements social work services to EveryAge PACE participants and families. Responsibilities include but are not limited to: assessment, treatment, teaching and counseling to participant, caregiver or other appropriate representatives. The Social Worker Interventions could include, individual participant contacts; appropriate collateral contact; participant and family education, assessment, and counseling; provision of resources; addressing mental health needs as they arise; ongoing case management; advocacy to ensure participant and caregiver needs are met and addressed; and disenrollment procedures. The Social Worker is the liaison between the interdisciplinary team, caregiver representatives, and community agencies.

Requirements

Master’s degree in Social Work from an accredited school of social work
Member of the Academy of Certified Social Workers (ACSW) or other NASW recognized certification preferred
Cardio Pulmonary Resuscitation (CPR) and First Aid certification required.
2 years’ experience working on an interdisciplinary team in a hospital, nursing home or community-based setting is preferable.
Minimum of 1 year working with the frail or elderly

Responsibilities

Performs in person initial assessments for enrollment of potential EveryAge PACE participants to obtain a complete psycho-social history, which may include descriptions of cognitive status, social supports, family dynamics, mental health and substance dependency, and other current issues and needs. Coordinates with the interdisciplinary team to develop a comprehensive care plan for each participant.
Conducts in person reassessments of enrolled participants every six months and as needed.
Shares the responsibility of performing Utilization Review at SNF, ALF, and hospitals.
Shares the responsibility of coordinating discharge with RN Care Manager and Provider.
Serves as primary point of contact for the assigned participant panel.
Functions as a member of the interdisciplinary team. Maintains regular attendance at, and participants in interdisciplinary team meetings; communicates participant changes, collaborates on care planning decisions and coordination for 24 hour care delivery.
On an annual basis (during annual or semiannual reassessment) presents the written participant rights documentation to assigned participants and or caregiver. In the event the participant is unable to understand the information, the social worker will ensure the caregiver or representative understands the participant rights. If there is a language barrier the Social Worker will provide the appropriate interpreter.
Encourages effective relationships among staff, geared to team-building and maintenance of a cohesive team.
Consults with and advises staff members as to the relationship of social, emotional, and cultural factors to health and medical care.
Shares the responsibility with RN Care Manager to coordinate skilled/assisted living facility admissions for short term or long term care needs, as well as for approved respite services.
Serves with RN Care Manager as point of contact for hospitalized participants. Travels to the hospital. Shares with RN Care Manager in obtaining daily progress notes from the hospital for all in-patient participant admissions.
Shares the responsibility with the RN Care Manager of attending care plan meetings, etc. for nursing home bound participants.
Coordinates 24-hour care delivery.
In the event of termination of EveryAge PACE, the social worker and RN Care Manager will coordinate the transitional care necessary to ensure continuation of care during and after termination. They shall assist participants to obtain reinstatement of conventional Medicare, and Medicaid benefits, transition participants care to other providers, make all appropriate referrals, make the participants medical records available to new providers with appropriate participant approvals.
Provides ongoing support, counsel, and education to participants and family regarding a variety of issues, including but not limited to: the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics and changing roles, PACE model, and PACE health services.
Works to assist participant to maintain housing through intervention with participant, caregivers, and housing agencies. Will proactively work to partner with participant and/or caregivers to maintain appropriate housing and assist participant to function at most independent community level possible.
Shares the responsibility with RN Care Manager to present requests to Interdisciplinary Team for, and coordinates admission/discharge to contracted facilities for temporary respites and permanent placement.
Performs home visits quarterly or as needed to assess living environment and support system.
Acts as facilitator for meetings with participant, family, caregivers, and community agencies to clarify, or problem solve issues regarding the Plan of Care. Mediates discussions between all parties.
If end of life care is appropriate, actively provides emotional support, grief work, education, and funeral/financial planning referral. Facilitates end of life or nursing home placement as needed.
Initiates referrals to external resources with community agencies such as Adult Protective Services, Housing Authority, or public utility companies. Advocates with these entities for purposes of maintaining community stability.
Assists participants and caregivers to complete Medical Durable Power of Attorney (MDPOA), Proxy, and Do Not Resuscitate (DNR) directives as needed.
Attends and actively participates in a variety of organizational meetings related to participant care or daily operations, in various in-services and community agency meetings. Serve as a resource to other team members and Day Center staff regarding topics such as dementia, difficult behaviors, and difficult personalities.
Completes and ensures completion of documentation of clinical service, in participants’ medical records including initial assessments, reassessments; change of status; temporary or permanent placements; hospital admissions and discharges; home and nursing home visits; and other significant events according to PACE documentation requirements.
Assists participants with Social Security Income (SSI) and Social Security Disability Insurance (SSDI) application process as needed.
Acts only within the scope of his or her authority to practice.
Maintains safe working environment. Follows all EveryAge PACE Policies and Procedures and OSHA safety guidelines.
Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants, and families.
Practices Standard precautions.
Participates in and supports Quality Improvement initiatives
Participates in continuing education classes and any required staff and training meetings. Maintains professional affiliations and any required certifications.