What are the responsibilities and job description for the Social Worker, MSW position at Desert Oasis Healthcare?
The Home Health Social Worker is a member of the Home Health team and provides services in accordance with an established plan of care that is based on the patient’s psychosocial assessment and the needs of the patient and family.
- Exercise discretion, use independent judgment and perform risk assessments. This includes Psychosocial, Mental Health, Home safety, Finances and support of the family system which could potentially affect coordination of the Home Health patient’s care.
- Assess prognosis, rehabilitation potential, functional limitations, activities permitted, medication and treatments. Determine when immediate intervention is needed and notify appropriate team members. Communicate and coordinate with the Physicians and the Care Team to protect the well-being of the patient by recommending short term interventions and long term goals.
- In coordination with the Management Team, triage the urgency level of referrals. Provide supportive or counseling services as needed. Conducts joint home health visits when appropriate.
- Act as consultant between the patient, his or her family, patient representative and the care team to assure that necessary information is shared to facilitate well informed health care decisions.
- Participate in the preparation, evaluation, and implementation of the plan of care to assure that the highest quality of social services is offered to patients/families and that the goals of continuity and comprehensiveness of care are achieved. Assist the Home Health case manager with safe discharge planning that may include transition to ambulatory behavioral health services when appropriate.
- Educate other team members in understanding the social and emotional factors related to health problems. This may include periodic educational in-services at staff meetings and annual skills day.
- Provide educational resources to the patient, family and patient representative to include, but not limited to, community resources, Advanced Directives, Durable Power of Attorney for healthcare, suicide and depression screening and government assistance programs.
- Determine when to involve Adult/Child Protective services, and mandated reporting as needed.
- Attend Home Health Case Conference, Interdisciplinary Advisory Committee, and In-service programs as needed.
- Perform other duties as assigned.
- Master of Social Work/Welfare.
- 1 year of home health, hospice or other home based program preferred.
- General knowledge of Medicare regulations, APS/CPS, community resources, and Geriatric populations.
- Must possess excellent communication, computer, and negotiation skills. Needs to have the ability to function as a team player and also work independently in the home setting.
- Valid California drivers license and proof of automobile insurance.
