The Medical Social Worker participates in the interdisciplinary care provided to home health patients. The Medical Social Worker functions to evaluate and develop a plan of care personalized to fit the patient’s emotional and social needs. The Medical Social Worker provides direction and supervision of the Social Worker Assistant as required and when involved in the patient’s plan of care. The Medical Social Worker works within CenterWell Home Health's company-specific policy and procedures, applicable healthcare standards, governmental laws, and regulations. Assesses the patient’s social and emotional state as it relates to his or her illness or injury, needs for care and his or her response to such treatment, and adjustments to care. Assesses any relationships of the patient’s medical and nursing needs in the home setting, financial resources, and available community resources. Provides any appropriate action to obtain available community resources to assist in resolving issues that may be impeding the patient’s recovery. Instructs patients and families in treating and coping with social and emotional response connected with Provides ongoing assessment of patient and family needs and responses to teaching Assists the physician and other health team members in understanding the significant social and emotional factors related to the patient’s health Participates in the development and periodic re-evaluation of the physician's Plan of Care for the patient. Observes, records, and reports changes in patients’ condition and response to treatment to the Clinical Manager and the Participates in the discharge planning process Participates as a member of the interdisciplinary care team in care coordination activities and acts as a resource to other health team members in the identification and resolution of patient needs Supervises instructs and evaluates the performance of the Social Work Assistant (BSW) to assure that all medical social services are provided to patients in compliance with Company, government, and professional standards Maintains and submits documentation as required by the company and/ or facility including any case conferences, patient/physician community contacts, visit reports progress notes, and confers with other health care disciplines in providing optimum patient care.