Outreach worker [h1.location_city]

Job Description

Job Description

McGregor PACE (Program of All-inclusive Care for the Elderly) is a community-based service program that provides in-home healthcare services to the elderly.

PACE is not a nursing home. But an alternative to nursing home placement, allowing Seniors to remain at home.

McGregor PACE is looking for a qualified Social Worker (MSW, LSW) who can work with an Interdisciplinary team to manage a caseload of 55-62 seniors along with team members.

McGregor PACE aims to have our participants remain in the community with the support of our Day Health Center services and staff. This candidate must be willing to conduct semi / annual assessments of PACE applicants and care plans.

The MSW along with other team members will be responsible for communicating with community agencies, participants, and families on an ongoing basis.

Hybrid Work Schedule : Monday – Friday (NO WEEKENDS! No Holidays! FIRST, SHIFT ONLY!) 2 days per week work from home.

Responsibilities :

• Conducts semi / annual assessments of PACE applicants.
• Works with nurse partner to ensure the interdisciplinary team has accurate information to assist participant and family members.
• Conducts psychological testing, i.e., Folstein Mini-Mental Exam, Geriatric Depression Scale Index and other cognitive tools, if needed.
• Plans social work interventions; accordingly, views problem resolution from the standpoint of client benefit.
• Interdisciplinary team support including completion of semi / annual comprehensive assessments of participants; day-to-day documentation; home visits; assessments of participants with a focus on physical, mental, emotional and psychological changes that are to be reported to the interdisciplinary team and reflected on the plan of care, as needed.
• Communicates with participants, caregivers, and guardians regarding concerns and issues; provides individual / family counseling as determined by the treatment plan.
• Communicate with community agencies that offer services to participants or families, if participant disenrolls from the PACE program.
• Corresponds with ODA and County Department of Jobs and Family Services, forwarding appropriate and timely required communication.
• Maintains information on alternative housing services, including methods for maintaining and distributing information to staff, families / caregivers, etc.
• Demonstrates ability to set priorities to managing caseload effectively with interdisciplinary team.
• Meets monthly with social work team to talk about problems and issues.
• Identifies participant and family education needs and provides appropriate teaching / information.
• Utilizes community resources appropriately while problem-solving.
• Assists in departmental and participant outcome data collection and analysis; participates in performance improvement initiatives, as relevant.
• Facilitate meetings with family members, if needed.
• Maintains contact with participants in whatever health care settings he or she resides in. Coordinating participants in appropriate discharge planning from skill / acute care or respite care.

Minimum Qualifications :

Preferred Qualifications :

We offer competitive compensation and EXCELLENT BENEFITS which include :