Overview
Provide social work services to patients, residents and families in post-acute and long-term care setting to assist them in continuity of care planning and in enhancing their capabilities of coping with illness, disability and daily functioning. Conduct comprehensive psychosocial assessments, resident interviews and complete all Social Work requirements for the Minimum Data Set (MDS 3.0). Assesses patients for discharge potential and review discharge status with Interdisciplinary Team. Makes appropriate referrals and coordinate the provision of services required upon discharge including home care, outpatient services, etc. to facilitate safe discharge into the community.
Responsibilities
- Provide Five Star Customer Service to all internal and external customers 100% of the time.
- Conducts admission assessments and interviews with residents and/or families to evaluate the appropriateness of placement; identifies the need for special services.
- Interprets residents' rights and responsibilities to families and staff.
- Advocates for residents' physical, mental and psychosocial well-being.
- Facilitates communication with the Interdisciplinary Team on behalf of residents including, but not limited to, medical, nursing, dietary, rehabilitation and psychiatric services.
- Coordinates and monitors needed available services for residents to assure optimum levels of physical, mental and psychosocial well-being and independence.
- Initiates and facilitates small group meetings of residents, families and staff directed at a fuller understanding of institutionalized residents, their health-related issues and fuller participation in improving residents' physical, mental and psychosocial well-being.
- Involves residents, families, Interdisciplinary Team and Administration, as appropriate, regarding matters such as bed retention, room changes and discharges.
- Interprets residents' needs and behavior; extends professional intervention to staff suggesting positive approaches, such as alternatives to the use of physical restraints and psychotropic drugs.
- Facilitates interdisciplinary care planning conferences involving residents and/or families; acts as designated representative in care planning conferences.
- Provides assistance and support to residents' families and designated representatives around institutionalization and health-related issues.
- Arranges for residents, families and/or designated representatives to meet with Department of Health staff as necessary.
- Participates, if requested by residents, in the organization and on-going functioning of the Resident and Family Councils.
- Coordinates and facilitates the referral of residents for needed and/or requested services and outside resources not available in the Center.
- Organizes bereavement counselling for residents, families, staff, friends and other affected individuals.
- Assesses residents' potential for discharge, reviewing discharge status with Interdisciplinary Team.
- Represents the Social Service/Admissions Department at agency and/or interdepartmental meetings as required.
- Is available at varying schedules, including weekends and evenings.
- Other responsibilities as assigned.
Qualifications
Master's in Social Work from an accredited graduate school of Social Work, Certified by the New York State Education Department (LCSW or LMSW).
2 years as an MSW in a health care setting