Social Worker - Primary Care At Home

Northwestern Memorial Healthcare • Wheaton, IL

13d • $35 - $45

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. The Social Worker reflects Northwestern Medicine’s mission, vision, and values; adheres to its Code of Ethics and Corporate Compliance Program; and follows applicable policies, procedures, guidelines, and regulatory and accreditation standards.

The role supports patients and families with complex psychosocial, economic, and emotional needs through screening, assessment, treatment planning, crisis intervention, discharge planning, care coordination, and connection to community resources. The Social Worker collaborates with care teams, patients, families, post-acute providers, and community agencies to promote safe, coordinated care and optimal clinical outcomes. Services may be delivered in private homes, group homes, or assisted living facilities, as well as via telehealth.

Requirements

• One full year of experience and/or internship in a medical social work role in an acute hospital setting or agency.
• Experience with maternal/child populations.
• 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).

Responsibilities

• Provide social work services to adult and geriatric patients in their residences and via telehealth.
• Travel to patient homes to deliver services.
• Work in patient residences, including private homes, group homes, and assisted living facilities, adapting to environmental conditions commonly encountered in home settings and during travel.
• Maintain effective communication and coordination with patients, families, and care teams.
• Provide services in accordance with professional standards and organizational requirements.
• Collaborate in screening, assessment, and discharge planning for high-risk patients and families with complex psychosocial and economic needs.
• Use expertise and problem-solving skills to achieve optimal clinical outcomes within effective resources and timeframes.
• Promote seamless and safe discharge throughout the continuum of care.
• Collaborate with the care team on discharge planning and community linkage for patients and families with complex social, economic, and emotional needs.
• Participate in care conferences and unit rounds, and keep care team members apprised of the current state and plan of care.
• Develop positive relationships with co-workers, care team members, and community resources.
• Work 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 to facilitate progress toward safe discharge.
• Partner with post-acute care providers and share appropriate information to create a seamless and safe discharge plan.
• Identify, assess, and respond to patient and family needs, incorporating developmental, psychological, cultural, and spiritual considerations.
• Address social and emotional needs that may affect a patient's response to medical treatment, including adjustment to illness, coping, functional impairment, mental illness, guardianship, compliance, financial and resource needs, substance abuse, cultural differences, bereavement, family welfare, abuse, neglect, and domestic violence; adoption matters in the mother/baby area are also included.
• Provide timely and effective 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 skills, and response to treatment.
• Advocate for patients and families and serve as a lead resource for referrals involving charity and financial resources, guardianship, family problems or conflicts, and competency issues.
• Assist with maintaining information and referral lists for post-acute care resources.
• Administer and interpret tests and measures of psychosocial functioning to support diagnosis of mental, emotional, behavioral, addictive, and developmental disorders and disabilities.
• Develop and implement assessment-based treatment plans, consulting with team managers, statutory and voluntary agencies, and patients’ relatives to support compliance with treatment plans.
• 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 addiction disorders or conditions, and make appropriate referrals or transfers to the correct level of care.

Benefits

• The company describes a wide range of benefits intended to support employees’ physical, emotional, and financial well-being and provide protection for unexpected life events.
• Tuition reimbursement.
• Loan forgiveness.
• 401(k) matching.

What This Job Offers

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