PACE - Master's Level Social Worker (MSW)

Jacksonville, FL 32205 PACE Partners of Northeast Florida, also known as PACE (Program for All-Inclusive Care for the Elderly), is a joint venture between Community Hospice & Palliative Care and Aging True. Care coordination for the program, the first of its kind in North Florida, is delivered at our beautiful day center known as The PACE Place.
Working at PACE is a rewarding and fulfilling position where you will be part of a national network of programs, offering seniors and their families the care, nutrition, rehabilitation, transportation, and supportive services they need to remain healthy, and living in their own home.
Our clinic and adult day center, located on the Westside of Jacksonville, is next to the Acosta-Rua Center for Caring. When you join our team, you receive the guidance needed to understand the demands and rewards of being a caregiver at PACE, helping to coordinate care and services for our participants. You go home each night knowing you made a difference by supporting our aging population.

• Perform in-person initial assessments for enrollment of potential PACE Place participants to obtain a complete psycho-social history, including descriptions of cognitive status, social supports, family dynamics, mental health and substance dependency, and other current issues and needs.
• Collaborate with the interdisciplinary team to develop a comprehensive care plan for each participant.
• Conduct in-person reassessments of enrolled participants every six months and as
• needed when participants’ conditions change.
• Maintain regular attendance at and participate in daily Interdisciplinary Team meetings, communicate participant changes and collaborate with team members in care planning decisions and coordination for 24-hour care delivery, which includes on call rotation for after hour collaboration or orchestration of patient needs. Schedule rotation to be determined with the Center Manager and Social Work team.
• Act as liaison with participants, caregivers, and community agencies regarding orientation to and ongoing relations with Interdisciplinary Team, day center, and other PACE Place staff.
• On an annual basis (during annual or semiannual reassessment) presents the written participant rights documentation to assigned participants and or caregiver. In the event the participant is unable to understand the information, the social worker will ensure the caregiver or representative understands the participant's rights. If there is a language barrier, the Social Worker will use an interpreter.
• Provide ongoing support, counseling, and education to participants and family regarding a variety of issues, including but not limited to: the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics, changing roles, PACE Place model and PACE Place health services.
• Work proactively to maintain participant housing through intervention with participants, caregivers, and housing.
• Assist participants to function at the most independent community-level possible.
• Present requests to Interdisciplinary Team (IDT) for and coordinate admission/discharge to contracted facilities for temporary respites and permanent placement.
• Perform home visits quarterly, or as needed, to assess the living environment and support system.
• Act as a facilitator for meetings with participant, family, caregivers, and community agencies to clarify or problem solves issues, including a plan of care. Mediate discussions between all parties.
• Provide referrals to subsidized housing and assisted living residences. This may involve completing applications, obtaining medical records, and accompanying participants to interview assessments and tours if the participant has no other support systems.
• Perform visits at a hospital within 24 hours of admission or on Monday if the participant is admitted on Friday or weekend. Coordinate hospital discharges in conjunction with interdisciplinary team and communication with attending physician. Communicate with family or caregivers frequently and as needed to update.
• If end-of-life care is appropriate, actively provide emotional support, grief counseling, education, and funeral/financial planning referral. Facilitate end-of-life or nursing home placement as needed.
• Initiate referrals to external resources with community agencies such as Adult Protective Services, Housing Authority, or public utility companies. Advocate for participants with these entities for purposes of maintaining community stability.
• Assist participants and caregivers to complete Medical Durable Power of Attorney (MDPOA), Proxy, and Do Not Resuscitate (DNR) directives as needed.
• Attend and actively participate in a variety of organizational meetings related to participant care or daily operations, in-services, and community agency meetings.
• Act as a resource to other team members and day center staff regarding topics such as dementia, difficult behaviors, and difficult personalities.
• Complete all documentation of clinical service in participants’ medical records, including initial assessments; reassessments; change of status; temporary or permanent placements; hospital admissions and discharges; home and nursing home visits; and other significant events according to PACE Place documentation requirements.
• Assist participants with Social Security Income (SSI) and Social Security Disability Insurance (SSDI) application process as needed.
• Assist participants and caregivers in filing grievances and appeals.
• Assist participants and family in keeping resources within guidelines for Medicaid eligibility and assistance if needed with annual Medicaid application.
• Assist participants disenrolling from PACE Place in coordinating insurance and referrals for other community or facility-based services as desired by the participant.
• In the event of termination of PACE Place, the social worker will act to coordinate the transitional care necessary to ensure the continuation of care during and after termination. Assist participants in obtaining reinstatement in conventional Medicare and Medicaid benefits, transition to other care providers, make referrals to other community-based or facility-based providers, and assist in providing the participants’ medical records to new providers with participant approvals.
• Act only within the scope of his or her authority to practice.
• Follow all Policies and Procedures and OSHA safety guidelines.
• Protect privacy and maintain the confidentiality of all company procedures, results, and information about employees, participants, and families.
• Practices standard precautions.
• Maintain a safe working environment, following PACE Place safety policies and procedures.
• Participate in and support Quality Improvement initiatives
• Participate in continuing education classes and any required staff and training meetings.
• Maintain professional affiliations, required certifications, and continuing education requirements.
• Only act within the scope of their authority to practice

• Master's degree in Social Work from an accredited school of social work by the Council on Social Work Education
• Be legally authorized (for example, currently licensed, registered or certified if applicable) to practice in the State in which they perform the function or action.
• Member of the Academy of Certified Social Workers (ACSW) or other NASW- recognized certification preferred
• Current driver’s license and proof of auto insurance
• CPR with First Aid or BLS certification required
  Experience:
  • Two (2) years of experience working on an interdisciplinary team in a hospital, nursing home, or community-based setting is preferable.
  • Have 1 year of experience working with a frail or elderly population OR, if the individual has less than 1 year of experience but meets all other job requirements, the candidate must receive appropriate training from the PACE organization on working with a frail or elderly population upon hiring.
  • Meet a standardized set of competencies for the specific position description established by the PACE organization before working independently.
  Skills and Knowledge:
  • Familiarity with the psycho-social issues of the frail and chronically ill and their caregivers.
  • Ability to provide psychosocial assessment and individual, family, and group counseling.
  • Ability to maintain accurate records and prepare clear and concise reports, correspondence, and other written materials.
  • Good public speaking skills with all-size groups.
  • Effective verbal and written communication skills.
  • Demonstrated ability to work in an interdisciplinary team setting.
  • Computer literacy.
  Work Environment:
  • Employee must be able to work effectively within an interdisciplinary team model, interfacing and collaborating with a wide range of clinical and social services disciplines who work together to manage the PACE Partners participants' care. The work setting is in an Adult Day Health Center and primary care clinic environment with moderate noise levels and controlled temperatures. Visits to patient homes, assisted and skilled nursing facilities is required and occurs as appropriate.
  Medical Clearance:
  • Be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact.