Job Summary:

This position is under the direct supervision of the Executive Director. Responsible for the direct social work case management services for PACE participants and their caregivers. Provides social services support to include participant screening, case management, counseling and referral. Provides appropriate interventions, emotional support, resource information, and assistance with discharge planning and community referrals as indicated. Able to work in diverse geriatric participant and staff populations; able to work independently and amicably in the interdisciplinary team setting.

Qualifications Per PACE Regulation:

Master's Degree from an accredited School of Social Work with two years of experience in a health related area as well as one year of experience working with the geriatric population. GSW required, LCSW preferred. Should possess a valid driver's license and reliable transportation. Position requires individual therapy skills geared toward geriatric participants, analytical thinking and problem solving abilities. Work to be performed includes visits to private homes of PACE enrollees and contracted facilities within the community. Position requires frequent travel in and around greater New Orleans area.

Per PACE Regulation:

• As a member of the PACE Interdisciplinary team, the social worker is responsible for the following:

• • Regularly informing the interdisciplinary team of the medical, functional, and psychosocial condition of each participant
  • Providing clinical consultation as an active member of the interdisciplinary care
  • team
  • Remaining alert to pertinent input from other team members, participants, and caregivers
  • Documenting changes of a participant's condition in the participant's medical record consistent with documentation policies established by the medical director
  • Providing routine updates to the participant's plan of care to reflect participant/caregiver based goals and interventions
  • Attending to system dynamics of the PACE organization to foster best use of resources, effective service delivery, and participant and family satisfaction
  • Advocating for the interventions that alleviate burden and facilitate coping for the participant and caregivers
  • Ensuring compliance with practice standards and codes

Per PACE Regulation:

• Each social worker is responsible for the following:

• • An initial comprehensive assessment to include a psycho-social perspective
  • Participation in the development of a participant centered plan of care
  • Periodic reassessments on a semi-annual basis or as a participant's condition dictates

• Unscheduled reassessments take place either due to a change in participant status or at the request of the participant or designated representative

Additional Essential Functions:

• Provides individual and family counseling, develops and leads group counseling and activities.
• Refers participants to appropriate community agencies or facilities, acts as a liaison with such organizations and as an advocate for participants.
• Encourages effective relationships amongst staff geared toward the building and maintenance of a cohesive team.
• Consults with and advises staff members as to the relationship of social, emotional and cultural factors which may impact the participant's health and medical care and the availability of social services in the community.
• Collaborates with the participant, caregiver and team members to identify options, goals and priorities for care; advanced care planning.
• Participates in quality improvement activities as assigned or indicated.
• Participates in program and policy development of the social work component of the program.