Social Worker - Primary Care At Home

Northwestern Memorial Healthcare • Wheaton, IL

4d

About The Position

The Licensed Social Worker-Home-Based Services provides services to adult and geriatric homebound patients in their residences and via telehealth. The role requires travel to patient homes and the ability to work effectively in a home-based care setting, including adapting to environmental conditions commonly found in private homes, group homes, and assisted living facilities.

The social worker coordinates screening, assessment, discharge planning, and community linkage for high-risk patients and families with complex psychosocial and economic needs. The role includes identifying and responding to patients’ and families’ social, emotional, cultural, spiritual, and developmental needs; providing crisis-oriented psychotherapy and referrals; advocating for patients and families; and developing and implementing assessment-based treatment plans. The social worker collaborates with care teams, post-acute providers, community resources, managers, agencies, and patients’ relatives to support safe transitions and effective care. The position also supervises and trains lower-level social workers, students, or interns.

Requirements

• One full year of experience and/or internship in a medical social work role in an acute hospital setting or agency.
• Licensed Social Worker (LSW).
• Valid driver’s license and auto insurance with a good driving record.

Nice To Haves

• Two years’ experience in an acute hospital setting.
• Master’s degree in social work.
• Minimum of two years of prior hospital or community-based social work experience.
• Licensed Clinical Social Worker (LCSW).
• ACSW (Academy of Certified Social Workers).
• Experience with maternal/child populations.

Responsibilities

• Provide social work services to adult and geriatric patients in their residences and via telehealth.
• Travel to patient homes to deliver services.
• Adapt to environmental conditions in patient residences, including pets, pet dander, dust, smoke, noise, clutter, varying indoor temperatures, and weather conditions during travel.
• Coordinate screening, assessment, and discharge planning for high-risk patients and families with complex psychosocial and economic needs.
• Use problem-solving skills to achieve optimal clinical outcomes within effective resources and timeframes.
• Promote safe, seamless discharge throughout the continuum of care and coordinate discharge planning and community linkage with the care team.
• Participate in care conferences and unit rounds, and keep care team members apprised of the current state and plan of care.
• Build positive relationships with co-workers, care team members, and community resources.
• Collaborate with care team members to identify at-risk populations and opportunities to improve care delivery and ongoing support.
• Make timely and appropriate referrals to ancillary support staff and partner with post-acute care providers to support safe discharge planning.
• Assess and respond to patient and family needs, including needs related to adjustment to illness, coping, functional impairment, mental illness, guardianship, treatment compliance, limited resources, substance abuse, cultural differences, bereavement, and family welfare concerns.
• Provide timely interventions for patients and families in emergencies and crises, including referrals to appropriate support resources.
• Educate team members about socioeconomic, emotional, and cultural issues that affect care delivery, coping, and response to treatment.
• Advocate for patients and families.
• Assist with referrals and coordination involving charity and financial resources, guardianship, family problems or conflicts, and competency issues.
• Maintain information and referral lists related to post-acute care resources.
• Administer and interpret tests and measures of psychosocial functioning for diagnosing mental, emotional, behavioral, addictive, and developmental disorders and disabilities.
• Develop and implement assessment-based treatment plans, consulting with team managers, agencies, and patients’ relatives to support compliance.
• Provide crisis-oriented psychotherapy and connect patients and families with appropriate resources.
• Supervise and train lower-level social workers, students, or interns.
• Apply specialized clinical knowledge and advanced clinical skills in assessment, diagnosis, and treatment of mental, behavioral, and addictive disorders or conditions, and make appropriate referrals or transfers to the correct level of care.

Benefits

• Tuition reimbursement
• Loan forgiveness
• 401(k) matching
• A wide range of benefits supporting employees’ physical, emotional, and financial well-being and protection from unexpected life events

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed