PACE Social Worker

Volunteers of America National Services (VOANS)•Montrose, CO

11d•$70,000 - $110,000•Onsite

About The Position

Join Senior Community Care of Colorado PACE as a Social Worker in Eckert, CO. This is more than a job; it’s a paid opportunity to serve others, live our mission, and make a meaningful impact. As a compassionate organization, we’re dedicated to serving others and fostering an environment where both our residents and team members thrive. If you’re ready to grow your career while making a difference, we’d love to connect with you. Senior Community Care of Colorado PACE is a community of Volunteers of America National Services, a subsidiary of the Volunteers of America parent organization. Proudly Great Place to Work® Certified for 8 consecutive years.

Requirements

Master’s degree in social work from an accredited school required.
Be legally authorized, currently licensed, registered or certified with the state of Colorado as a SW-C or LSW, OR be licensed in the state of Colorado as a LCSW.
Must have current Cardiopulmonary Resuscitation (CPR) certification
Must have a valid driver’s license, proof of insurance and have means of transportation.
A minimum of one year’s experience working with frail or elderly population required.

Nice To Haves

Experience working on a multi-disciplinary team in a hospital, nursing home or community-based setting is preferable.

Responsibilities

Routinely assesses the needs of participants and families and determines the most appropriate and effective social services interventions to meet participant goals.
Works in coordination with the IDT, Behavioral Health Specialist, Chaplain, contracted providers, and others to implement the plan of care and to provide psych/social interventions.
Acts as an education resource for the PACE team and supports the organization’s goal to provide high-quality, person-centered care to all participants.
Performs in-person initial assessments for enrollment of potential Senior CommUnity Care participants to obtain a complete psychosocial history, which may include descriptions of cognitive status, social supports, family dynamics, mental health and substance dependency, and other issues and needs.
Coordinates with the Interdisciplinary Team to develop a comprehensive plan of care for each participant.
Conducts in-person re-assessment of enrolled participants every six (6) months and as needed.
Functions as a member of the Interdisciplinary Team. Maintains regular attendance at and participates in Interdisciplinary Team meetings; communicates participant changes, collaborates on plan of care decisions and coordination for twenty-four (24) hour care delivery.
Provides ongoing support, counsel, and education to participants and family regarding a variety of issues, including but not limited to: the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics and changing roles, PACE model and PACE health services.
Presents requests to Interdisciplinary Team for and coordinates admission/discharge to contracted facilities for temporary respites and permanent placement.
Acts as facilitator for meetings with participant, family, caregivers, and community agencies to clarify, or problem-solve issues regarding the plan of care. Mediates discussions between all parties.
If hospice care is appropriate, actively provides emotional support, grief work, education, and funeral/financial planning referral. Facilitates hospice or nursing home placement as needed.
Initiates referrals to external resources with community agencies such as Adult Protective Services, Housing Authority, or public utility companies. Advocates with these entities for purposes of maintaining community stability.
Assists participants and caregivers to complete Medical Durable Power Of Attorney (MDPOA) Proxy, and Do Not Resuscitate (DNR) directives as needed.
Attends and actively participates in a variety of organizational meetings related to participant care, including but not limited to: Morning Meeting, Intake and Assessment Meeting, various in-services and community agency meetings.
Acts as a resource to other team members and day center staff regarding topics such as dementia, difficult behaviors, and difficult personalities.
Completes and ensures completion of documentation of clinical service, in participant’s medical records including initial assessments, re-assessments, change of status, temporary or permanent placements, hospital admissions and discharges, home and nursing home visits, and other significant events according to Senior CommUnity Care documentation requirements.
Assists participants and caregivers in filing grievances.
Acts within scope of his or her authority to practice.
Follows all Senior CommUnity Care policies and procedures and Occupational Safety and Health Administration (OSHA) safety guidelines.
Protects privacy and maintains confidentiality of all company procedures, results, and information about employees, participants, and families.
Maintains safe working environment. Follows Senior CommUnity Care Safety policies and procedures.
Participates in and supports Quality Improvement Initiatives.
Participates in continuing education classes and any required staff and training meetings. Maintains professional affiliations and any required certifications.
Performs other duties as required.