Social Worker

Arden House (2) -

HIGHBRIDGE HEALTHCARE : Social Worker

Reports To: Director of Social Services

POSITION SUMMARY:

The Social Worker works with patients/residents and their family members/significant others within the facility through use of the psychosocial perspective identifying their strengths, social, emotional, and mental health needs along with providing, developing, and/or aiding in the access of services to meet those needs. The Social Worker shall provide patients/residents with the highest practical level of physical, mental, and psychosocial well-being and quality of life. Services are provided in accordance with the National Association of Social Workers (NASW) Code of Ethics and compliance with federal, state, and local guidelines and regulations, HIGHBRIDGE policies & procedures, and standards of care.

RESPONSIBILITIES/ACCOUNTABILITIES:

Administrative - Assists with planning and implementing a comprehensive Social Services program. Understands and implements departmental policies and procedures as part of the facility’s interprofessional team to comply with federal and state regulations. Is an active participant and contributor to center’s Quality Assurance and Performance Improvement process requested by the Social Services Director. Understands and meets all government, organizational and state specific requirements for Social Work documentation in electronic medical record. Assures timely entries in the patients’/residents’ charts to include, but not limited to: psychosocial assessment; person-centered care plan to address strengths, problems, needs, and interventions; substantiation of psychosocial interventions; progress toward, and/or completion of goals.

Advocacy -Works with the interdisciplinary team to promote and protect patients/residents rights and the psychosocial well-being of all patients/residents Prevents addresses, and reports patient/ resident abuse as mandated by law and professional licensure. Works with patients/residents, families, and significant others to provide support and information for taking a more proactive role in self-advocacy to improve the quality of life/care for individual patients/residents. Responds to issues identified by patients/residents and families to determine satisfaction with services.

Clinical -Completes a comprehensive Psychosocial Assessment for each patient/resident that identifies social, emotional, and psychological needs and strengths. Assesses each patient/resident for discharge. . Screens for trauma history and develops interventions accordingly. Monitors for Mental Illness and/or Intellectual Disability (Pre-Admission Screen and Resident Review) on admission and screens as needed throughout the course of stay. Conducts patient/resident, family, and staff interviews and ensures that relevant MDS sections (i.e. cognitive, mood, behavior, and patient goal setting) and Care Area Assessments are completed in accordance with regulation. Participates in the development of a written, person centered interprofessional plan of care for each patient/resident that identifies the psychosocial needs/issues of the patient/resident, the goals to be achieved for those needs/issues, and the appropriate Social Services interventions. Provides therapeutic interventions to assist patients/residents in coping with their transition and adjustment to a long-term care facility including the social, emotional, and psychological needs. Facilitates groups for patients/residents and/or family members/significant others as appropriate to meet their needs. Educates and supports patient/resident and family members/significant others to orient them to placement at facility and facilitate adjustment. Facilitates patient/resident transfer throughout the center to ensure a seamless transition and patient/resident adjustment. Provides interventions, staff support and education to address catastrophic events that occur during the patient’s/resident’s stay in the facility. Participates as part of the interprofessional care team in providing interventions to mitigate behavior or mood symptoms. Serves as a resource to patients/residents, families/significant others and staff for conflict resolution as needed. In collaboration with the interprofessional team, promotes and ensures health care decision making process is implemented and in compliance with state regulations and HIGHBRIDGE Advance Care Planning and Goals of Care processes. Arranges and conducts patient/resident family meetings as needed.

Discharge Planning -Identifies patient/resident discharge goals at admission and documents initial discharge plan and involves the patient/resident and family throughout the process. Works through care planning and utilization management throughout the course of the stay to identify strengths and needs to ensure an appropriate discharge plan is formulated. As part of interprofessional team, identifies discharge teaching needs. Collaborates in the communication of the estimated discharge date to patient/resident, family and staff.

Education - Educates staff regarding the role of the Social Services in the facility and the psychosocial needs of the patients/residents and their families/significant others including the problems of aging and disability as requested by Social Services Director. Educates patients/residents and families/significant others regarding their rights and responsibilities, health care decision making/advance directives, effective problem solving and the extent of community, health and social services that are available to them, including those necessary for effective discharge planning.

SPECIFIC EDUCATIONAL/VOCATIONAL REQUIREMENTS:

1. Bachelor’s degree in Social Work or Human Services field required. Must possess any certifications/licensures as required by State of employment to practice in long term care.

2. 1-3 years of supervised social work experience in health care setting working directly with individuals preferred.

3. Additional certification such as Geriatric Case Management, Hospice & Palliative Care, Gerontology, Clinical Social Work, Health Care, Nephrology, Mental Health, and/or Substance Use preferred.