Social Worker

Mount Sinai Medical Center of Florida•Hialeah, FL

About The Position

The Social Worker performs psychosocial assessments and reassessments for potential and enrolled Eldercare participants, collaborating with the interdisciplinary team to create and coordinate comprehensive care plans. The role provides ongoing support, counseling, education, advocacy, and referrals to participants and their families, and coordinates care transitions, placement, and end-of-life support as needed. The Social Worker also serves as a liaison among participants, caregivers, Eldercare staff, and community agencies; facilitates meetings and mediates discussions; supports participants with benefits applications and advance-care planning documents; participates in quality-improvement initiatives; and practices within the scope of their authority. The role requires a Master of Social Work degree from a CSWE-accredited school and BLS or CPR certification.

Requirements

Master of Social Work degree from a school accredited by the Council on Social Work Education.
BLS or CPR certification.
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.

Nice To Haves

Two years of social work experience working on an interdisciplinary team in a hospital, nursing home, or community-based setting is desired.

Responsibilities

Perform in-person initial assessments of potential Eldercare participants and obtain a complete psychosocial history, including cognitive status, social supports, family dynamics, mental health, substance dependency, current issues, and needs.
Collaborate with the interdisciplinary team to develop a comprehensive care plan for each participant.
Conduct in-person reassessments of enrolled participants every six months and as needed when their conditions change.
Attend and participate in daily Interdisciplinary Team meetings, communicate participant changes, and collaborate on care planning and coordination for 24-hour care delivery.
Serve as a liaison with participants, caregivers, and community agencies regarding orientation to and ongoing relations with the Interdisciplinary Team, day center, and other Eldercare staff.
Provide ongoing support, counseling, and education to participants and families on topics including aging, dementia, grief and loss, end of life, disease processes, family dynamics, changing roles, and Eldercare services.
Present requests to the Interdisciplinary Team and coordinate admissions to and discharges from contracted facilities for temporary respite or permanent placement.
Facilitate meetings with participants, families, caregivers, and community agencies to clarify or resolve issues, including care-plan issues, and mediate discussions among parties.
Refer participants to subsidized housing and assisted living residences; assist with applications and records, and accompany participants to interviews or tours when needed and when they lack other support.
Refer participants to community resources, including Adult Protective Services, Housing Authority, and public utility companies, and advocate for them to help maintain community stability.
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 authority and adhere to the philosophy and goals of Eldercare.