GENERAL DESCRIPTION: Under the supervision of the Social Work Manager, the Social Worker is responsible for providing outreach, social services, crisis, counseling and intervention, advocacy, and case management to participants enrolled in the program and their families. It is the responsibility of the Social Worker to ensure that cultural/ethical considerations of participants are addressed in long term care programming planning and treatment.

RESPONSIBILITIES:

1. Provides case management services to an assigned caseload of participants.
2. Conducts and completes initial social services assessments and develops corresponding treatment plans within ten (10) working days of the participant’s enrollment.
3. Completes routine assessments and plans of care for each participant by the scheduled I/A date; completes re-assessments and plans of care within seven-two (72) hours of participant’s or family’s request, if such is the case.
4. Initiates and completes episodic care plan updates as indicated.
5. Complete home safety screen as per fall policy if no home health services are in place.
6. Completes Plan of Care review and Signature Page with the participant, facility and/or decision maker within 15 business days of dated IDT completed Care Plan.
7. Participates as an integral member of the multidisciplinary team to diagnose problems, formulate treatment plans and evaluate progress of participants.
8. Interprets the social aspects of participant condition or status changes to the IDT at the I/A meetings or the daily participant Plan of Care Committee (PCP) and to family/caregiver as expeditiously as required by the participant’s condition.
9. Visiting participants that are hospitalized within 24 hours of admission and begin the discharge planning process to ensure a smooth transition upon discharge.
10. Serves as a liaison with the participant’s family via home visits, family conferences and telephone contacts, utilizing the appropriate approach to keep all parties informed.
11. Establishes and maintains a positive relationship with BSHS Contracted Assisted Living/Foster Homes/ Nursing Home Facilities in order to ensure that when participants need placement or respite, their needs will be met appropriately and on a timely basis.
12. Assist with permanent and respite placements as indicated.
13. Complete placement cost contract and submit for approval.
14. The SW will attend facility case conferences as necessary.
15. Complete Coastal Alert referral when approved by the IDT.
16. Complete disenrollment documents (death and non-death).
17. Complete MSUR Service Delivery Day Unit form on a timely basis.
18. The SW will assist in training/supervision of social work interns (students) and new hires, coordinating their assignments with the Social Work Manager.
19. The SW will serve as a liaison and advocate for participants and their families. With agencies such as Social Security, Health and Human Services Commission, the Housing Authority, Adult Protective Services, Probate Court, etc.
20. The SW will provide appropriate documentation for internal and external reporting purposes; i.e., psychosocial assessments, progress notes, reports of changes in status/condition, etch within a 24 hour time frame of contact.
21. The SW will complete interventions on care plan within 3 months of dated IDT completed Care Plan.
22. The SW will be responsible in assisting participants and completing reports that are required on an annual basis (i.e., Medicaid renewals, recertification)
23. The SW will provide advanced directives education on at least a biannual basis and assist with completion as indicated.
24. The SW will participate in ongoing communication to participant/decision maker about Participant Rights, Grievance and Appeals Process, and Care Planning.
25. The SW will assist with transition to comfort care.
26. The SW will identify participants eligible for transfer and initiate transfer checklist.
27. The SW will assist in facilitating staff in-services by contacting outside presenters who have the expertise in providing services to the elderly.
28. The SW will refer participant and family members to community resources as needed.
29. The SW will perform on-call duties from Friday to Friday, reporting physician on-call and any other staff person who is on call during the same time. SW will cooperate with other disciplines to trouble-shoot and resolve difficulties that arise while performing on-call duties.
30. The SW is a member of the Emergency Preparedness Team and will need to be available for emergency plan as indicated (natural disaster, emergency center closing, etc.)
31. The SW will familiarize self with, understand and implement the Social Services department policies and procedures.
32. SW will complete mandatory initial and ongoing training hours as scheduled.
33. SW will be personally responsible for maintaining current SW licensure training hours as required by the Texas State Board of SW Examiners.
34. Other duties as assigned by the Social Work Manager and/or PACE Center Director.

Required Skills

KNOWLEDGE/SKILLS/ABILITIES:

• A dependable individual with a strong knowledge base, understanding and appreciation of the elderly.
• Possesses the ability to communicate effectively to participants and community groups the philosophy, objective and policies of Bienvivir Senior Health Services.
• Works well within the ethical principles of the Social Work Code of Ethics, and exhibits appropriate behavior when related to participants and colleagues.
• Ability to work as a member of an interdisciplinary team and is able to communicate effectively with staff, participants, and family members.
• Must be bilingual (Spanish/English).
• Must have dependable transportation, valid driver’s license and automobile liability insurance.

Required Experience

QUALIFICATIONS / REQUIREMENTS: EDUCATION/EXPERIENCE: A. A graduate of an accredited university with a Master’s degree in Social Work and licensed by the Texas State Board of Social Worker Examiners. B. One year experience in providing Social Services to a frail or elderly population preferred. C. Knowledge and experience working with the geriatric population and family systems. D. Knowledge of community referral system for community services.

KNOWLEDGE/SKILLS/ABILITIES:

• A dependable individual with a strong knowledge base, understanding and appreciation of the elderly.
• Possesses the ability to communicate effectively to participants and community groups the philosophy, objective and policies of Bienvivir Senior Health Services.
• Works well within the ethical principles of the Social Work Code of Ethics, and exhibits appropriate behavior when related to participants and colleagues.
• Ability to work as a member of an interdisciplinary team and is able to communicate effectively with staff, participants, and family members.
• Must be bilingual (Spanish/English).
• Must have dependable transportation, valid driver’s license and automobile liability insurance.