Social Worker

Mount Sinai Medical Center•Hialeah, FL

About The Position

The Social Worker performs in-person initial assessments for potential Eldercare participants, gathering a complete psychosocial history that addresses cognitive status, social supports, family dynamics, mental health and substance dependency, and other current needs. The role collaborates with the interdisciplinary team to develop comprehensive care plans and conducts in-person reassessments every six months and as needed when participants’ conditions change. The Social Worker participates in daily Interdisciplinary Team meetings, communicates participant changes, and coordinates care planning and 24-hour care delivery. The role serves as a liaison among participants, caregivers, community agencies, the day center, and Eldercare staff, and provides ongoing support, counseling, and education to participants and families on aging, dementia, grief and loss, end-of-life concerns, disease processes, family dynamics, and Eldercare services. Additional work includes coordinating respite admissions and permanent placements, facilitating meetings and mediating discussions, connecting participants with housing and community resources, assisting with advance-care directives and Social Security applications, and coordinating services when participants disenroll. For participants needing end-of-life care, the Social Worker provides emotional support and grief counseling and helps with education, referrals, and placement. The role also supports quality-improvement initiatives and practices within the scope of professional authority.

Requirements

Master of Social Work degree from an accredited school of social work accredited by the Council on Social Work Education.
BLS or CPR certification required.

Nice To Haves

Two years of social work experience on an interdisciplinary team in a hospital, nursing home, or community-based setting is desired.
One year of experience working with a frail and elderly population.

Responsibilities

Perform in-person initial assessments of potential Eldercare participants and obtain a complete psychosocial history.
Collaborate with the interdisciplinary team to develop comprehensive care plans.
Conduct in-person reassessments every six months and as needed when participant conditions change.
Attend and participate in daily Interdisciplinary Team meetings; communicate changes and collaborate on care planning and coordination of 24-hour care.
Serve as a liaison among participants, caregivers, community agencies, the Interdisciplinary Team, day center, and other Eldercare staff.
Provide ongoing support, counseling, and education to participants and families on aging, dementia, grief and loss, end-of-life issues, disease processes, family dynamics, and Eldercare services.
Present requests to the Interdisciplinary Team and coordinate admissions to contracted facilities for temporary respite and permanent placement.
Facilitate meetings with participants, families, caregivers, and community agencies to clarify or resolve issues, including care plans, and mediate discussions.
Refer participants to subsidized housing and assisted living residences; assist with applications, records, interviews, and tours as needed.
Refer participants to external community resources, including Adult Protective Services, Housing Authority, and utility companies, and advocate for participants with those entities.
Assist participants and caregivers with advance directives, Medical Durable Power of Attorney, Proxy, and Do Not Resuscitate directives as needed.
Assist participants with Social Security Income and Social Security Disability Insurance applications as needed.
Coordinate insurance and referrals to other community- or facility-based services for participants disenrolling from Eldercare, as desired by the participant.
Provide emotional support, grief counseling, education, and funeral or financial-planning referrals when end-of-life care is appropriate; facilitate end-of-life or nursing-home placement as needed.
Participate in and support Quality Improvement initiatives.
Practice only within the scope of professional authority and adhere to Eldercare’s philosophy and goals.