The Clinical Social Worker (CSW) at the PACE Your LIFE Program contributes the profession’s unique psychosocial perspective to the interdisciplinary evaluation, assessment, plan of care, ongoing services, and disenrollment processes that occur once the PACE participants begin the intake process and continue with ongoing services. The CSW provides basic casework and consultation for the PACE participants, as well as facilitates communication between participants, their family and the PACE Interdisciplinary Team (IDT). The CSW ensures efficient and appropriate coordination of care in order to optimize the health status and quality of life of PACE participants. The CSW’s interventions may include participant and family education, assessment and counseling, mobilizing resources, addressing mental health needs, ongoing case management, and advocacy to ensure participants’ needs are addressed and disenrollment procedures are followed.
Essential Duties and Responsibilities:
1. Uses all information sources available, assesses participants’ psychosocial health status and social work needs.
a. Completes assessments at admission and for required care planning according to regulatory requirements and as condition change indicates.
b. Determines participant and family needs related to social support, financial support, counseling and housing.
c. Confers with participant and family to identify participant goals and expectations
d. Coordinates with the Interdisciplinary Team to develop a comprehensive care plan for each participant.
2. In cooperation with the Interdisciplinary Team, plans and performs psychosocial interventions designed to keep the participant in the community and enhance quality of life to the greatest extent possible.
3. Provides individual and group counseling to participants and their families as needed or prescribed in the care plan.
4. Assists in the completion of participants’ healthcare wishes and advance directives in cooperation with their primary care physician and/or nurse practitioner, the participant and family.
5. Provides discharge planning in the event of disenrollment.
6. Acts as participant advocate and liaison between participant and various governmental and private agencies in order to maximize the participant’s support network and obtain needed services:
a. Facilitates communication between participant and various government programs such as Medicaid, SSI, Medicare and Social Security
b. Reviews Medicaid eligibility, monitors time frame for recertification
c. Facilitates Medicaid applications for certification and recertification in conjunction with Medicaid Eligibility Specialist
7. Participates in interagency meetings as needed and assists participants in obtaining housing and eligibility for low-income housing options.
8. Evaluates need for and assists with the set-up of money management systems for participants who require assistance.
9. Keeps up-to-date on changing rules and regulations regarding Medicaid and Medicare eligibility and other entitlement programs and services.
10. Acts as participants’ advocate and liaison between participant, family and Care Team:
a. Facilitates communication between participant, family and Care Team to maximize or maintain participant support systems.
b. Facilitates or participates in family meetings as required
11. Facilitates the Participant Council to create and maintain a vehicle for dialogue between participants and the Care Team, and to empower participant responsibility.
12. Conducts family support groups, education or training sessions, and routine family caregiver meetings for education, support and dialogue.
13. Works with Program Director to provide orientation and in-service programs for Care Team to enhance staff understanding of psychosocial issues and to meet regulatory requirements and support performance improvement.
14. Coordinates with mental health-related providers, including drug and alcohol treatment, to arrange appointments and share pertinent information.
15. Participates in surveys and inspections made by authorized government agencies.
1. Serves on, participates in, and attends meetings of various teams and/or committees, as required and appointed by the Program Director.
2. Provides written and/or oral reports of the social services programs and activities, as required or may be directed by such committees.
3. Evaluates and implements recommendations from established committees as they may pertain to social services.
4. Performs administrative requirements, such as completing necessary forms, reports, etc., and submits such to Program Director as required.
5. Makes written and oral reports/recommendations to the Program Director concerning the operation of the Social Services Department.
6. Reviews departmental complaints and grievances from participants and makes written reports to the Program Manager of action(s) taken.
7. Assists the Quality Improvement Committee in developing and implementing appropriate plans of action to correct identified deficiencies.
8. Assures that all progress notes charted are informative and descriptive of the services provided and of the participant’s response to the service.
9. Maintains a reference library of written material, laws, etc., necessary for complying with current standards and regulations that will provide assistance in maintaining quality social service.
10. Meets with administration, medical and nursing staff, as well as other related departments in planning social service programs and activities.
11. Maintains an excellent working relationship with other department supervisors and coordinates social services to assure that daily social services can be performed without interruption.
1. Must work the days and hours necessary to perform all assigned responsibilities and tasks. Must be available (especially during the regular business hours or shifts) to communicate with supervisors, customers, vendors and any other person or organization with whom interaction is required to accomplish work and employer goals.
2. Must be punctual and timely in meeting all requirements of performance, including but not limited to:
a. Attendance standards and work deadlines
b. Beginning and ending assignments on time
c. Scheduled work breaks, where applicable
3. Must maintain courteous, professional and effective working relationships with employees at all levels of the organization.
4. Must develop and maintain courteous and effective working relationships with clients, vendors and/or any other representatives of external organizations.
5. Must assume responsibility for providing timely, appropriate responses to requests/suggestions/complaints or refer such comments to the appropriate person. When referring requests/suggestions/complaints to another individual, the employee must follow-up in writing to the individual and must maintain an accessible copy of the referral, or follow company guidelines.
6. Must communicate information and state problems or challenges to be resolved in a clear, concise, courteous, nondiscriminatory and professional manner, and be able to provide clarification, as necessary.
7. Must show respect for the opinions of others and behave in such a way as to ensure an atmosphere free from needless interruptions, difficulty and/or discrimination.
8. Must receive and provide clear, constructive feedback regarding work performance (to/from individuals or groups) and be able to provide clarification, as necessary.
9. Must handle in a constructive, non-disruptive manner, the multiple business, organizational and interpersonal changes or stresses that may exist in the employee’s work, work processes, dealings with other personnel, and supervision (provided or received). (“Work processes” include but are not limited to, how work is performed, supervised or distributed, how problems are solved, and how decisions are made.)
10. Must be sufficiently adaptable to accept and perform, in a timely and effective manner, work assignments that are outside the normal (day-to-day) routine.
11. Must adapt, with minimal or no advance notice, to changes in how business is conducted and work is accomplished.
12. Performs related duties as required. (“Related duties as required” are duties that may not be specifically listed in the class specification or position description, but are within the general occupational series and responsibility level typically associated with the employee’s class of work.)
a. Master’s degree in Social Work required
2. Credentials/Licensure Required:
a. Current Social Work license in Delaware preferred
a. Three-years experience in long-term care or home care/geriatric setting
b. Proficiency with Word, Excel, Outlook, and electronic health records strongly preferred
4. Age of Patients Rendered Care:
a. Adult and geriatric patients
*** Freedom from illegal use of drugs, and freedom from use and effects of use of drugs and alcohol in the workplace.
*** Persons who have been found guilty by a court of law of abusing, neglecting or mistreating individuals in a healthcare-related setting are ineligible for employment in this position.
Knowledge and Skills:
To perform the job successfully, an individual should demonstrate the following competencies:
1. Good analytical abilities coupled with excellent written and verbal skills to explain technical information to managers and systems users.
2. Professional level of confidentiality in handling participant information.
3. Ability to work under the stress of meeting many requests and deadlines that sometimes conflict.
4. Ability to exchange information clearly and concisely with the supervisor, managers, and co-workers.
5. Ability to balance team and individual responsibilities.
6. Ability to report accurately and timely facts and technical information.
7. Ability to receive guidance, follow work rules, and follow safety and security practices.