Social Worker – Dementia Navigation Services (BSW)

Carilion Medical Center•Roanoke, VA

6d•Onsite

About The Position

In collaboration with the health care team, the social worker assists patients and families with personal and environmental difficulties with predisposed illness or interferes with obtaining maximum benefits from medical care. Services include providing patient and families with the psychosocial support needed to cope with disease and life limiting illness, advising family and caregivers, providing education and support, and making referrals for other services as needed or requested. The Social Worker (BSW) provides care navigation, resource coordination, and supportive services to individuals living with dementia and their caregivers. This role focuses on guiding clients through healthcare, community resources, and long-term support systems while promoting quality of life, safety, and independence. This will be a grant funded position for the Navigation program, starting out as a 1-year position conditional upon grant funded agreement being extended. Company equipment.

Requirements

Bachelor's degree in social work required.
Social work experience in health care setting preferred.
Critical thinking and creative problem-solving skills to move patients effectively and efficiently through the continuum of care.
Ability and willingness to work as an integral member of a multi skilled team

Responsibilities

Conduct initial and ongoing assessments of individuals with dementia and their caregivers to identify needs, preferences, and barriers.
Develop and implement individualized service plans in collaboration with clients, families, and interdisciplinary teams.
Connect clients to appropriate medical, behavioral health, social, and community-based services (e.g., home health, adult day services, and respite care).
Assist with transitions of care, including hospital discharge, long-term care placement, or in-home support expansion as needed.
Provide education on dementia progression, caregiving strategies, and available resources.
Offer emotional support and guidance to caregivers, addressing stress, burnout, and coping strategies.
Advocate for client rights, dignity, and person-centered care approaches.
Maintain knowledge of local, state, and federal programs (e.g., Medicaid waivers, aging services, transportation, housing supports).
Assist clients with applications, referrals, and eligibility processes.
Coordinate with community partners to ensure continuity of care.
Monitor client progress and reassess needs monthly.
Document all client interactions, care plans, and service outcomes in accordance with organizational and regulatory standards.
Identify and address safety concerns, including risks related to wandering, medication, adherence, or neglect.
Work closely with healthcare providers, case managers, and community organizations.
Participate in interdisciplinary team meetings and case reviews.
Support outreach efforts and community education related to dementia services.
Provides psychosocial assessments of patients and families to identify emotional, social, and environmental strengths and problems related to their preventative health management, diagnosis, illness, treatment, and/or life situation.
Utilizes social work experience to plan and coordinate patient care.
Coordinates the transition plan with the care team and recommends further treatment for the patient to achieve optimal level of healthy lifestyle, behaviors, and functioning.
Evaluates the plan at appropriate intervals and modifies the plan as necessary.
Monitors, evaluates, and records client progress according to measurable goals described in treatment and care plan.
Monitors healthcare resource utilization such as ED, urgent care, admissions, or frequent office visits.
Collaborates with team to address unnecessary utilization and plans for appropriate support to modify process behaviors.
Arranges and coordinates assistance/referrals for unmet patient/family needs, to include social service, financial, and insurance applications and follow up, medications, DME, and transportation to/from clinic appointments.
Plan of care promotes compliance as well as considers appropriate utilization of resources.
Advocates on behalf of the patient.
Participates in care transitions planning and post-discharge follow up to assess psychosocial and support needs and reinforces patient self-management expectations and goals.
Collaborates with other professionals to evaluate patients’ medical or physical condition and to assess patient needs.
Collaborates with community agencies and resources to develop a comprehensive knowledge base of available resources for patients and families.
Networks with community resources to build strong working relationships.
Maintains an extensive knowledge of benefit plans, regulatory guidelines and resources and serves as a resource to maximize utilization and cost effectiveness.
Refers patient or family to community resources to provide access to services such as financial assistance, legal aid, or housing.
Refer to DSS with suspected abuse or neglect of child or adult.
Meets documentation standards for quality, timeliness, and confidentiality of medical records in accordance with organizational and departmental defined policies and procedures.
Maintains records and statistics in accordance with department and medical center policies.
Remains current with social work and health care developments and seek to increase further enhancement of job-related knowledge.
Identifies social problems and advocate for change.
Provides education and self-management strategies to patients and families around issues related to adaptation of the patient’s health and addressing any contributing barriers to achieving goals.