Social Worker
Woburn, Massachusetts
Organization Facility: Beth Israel Lahey Health at Home Category: Social Services Job ID: JR54142 Date posted: 06/06/2024Job Type: Per Diem
Time Type: Part time
Work Shift: Rotating (United States of America)
FLSA Status: Non-Exempt
When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.
Job Description:
Home Health Social Worker--Per Diem
The Home Health Social Worker provides a wide range of services to patients and families while consistently exercising judgment and discretion to determine the patient and family’s unique spiritual/ cultural beliefs, strengths, coping skills, etc. Assessment is ongoing and the Plan of Care reflects the Medical Social Worker’s analysis of and conclusions regarding unique bio-psychosocial needs of the patient/ family.
Job Description:
Direct Patient Care
- Coordinates social work services for patients and their families
- Manages IDT patient plan of care for social work interventions
- Provides person and family centered, comprehensive psychosocial assessment
- Provides psychosocial interventions with the highest integrity related to cultural appropriateness and developmental stage along the continuum of illness including:
- supportive counseling
- psychoeducation
- anticipatory guidance
- advocacy
- facilitation of family meetings
- linkage to community resources
- non-pharmacological pain and symptom management
- Reinforces patient and family personhood and coping as they negotiate the complexities of illness
- Provides clinical guidance and consultation to interdisciplinary teams
- Provides safe and comprehensive care coordination and discharge planning as indicated. Assesses team coping with challenging clinical cases. Provides guidance and debriefing as necessary.
- Makes scheduled and unscheduled visits as a member of the Interdisciplinary Team to provide psychosocial assessment of patient/family functioning. Schedules and prioritizes visits based on the acuity level of the patient/family. Makes informational visits as requested by manager to prospective patients/families.
- Provides written psychosocial assessment of patient and family and communicates the following in a timely manner: psychosocial strengths and weaknesses, including coping skills, grief reactions, support systems, high risk factors for complicated bereavement and the need for community resources.
- Provides individual and/or family counseling and reassesses psychosocial factors during every visit to assure optimal outcomes. Initiates and /or participates in patient care conferences or family meetings as needed or requested and completes appropriate documentation in the electronic record.
- Upon assessing patient/family needs, the Social Worker makes all appropriate referrals to other community agencies in a timely manner; these include, but are not limited to accessing and applications for financial resources, nursing home placements, etc.
- As a Mandated Reporter, demonstrates knowledge of family violence, child/elder/disabled neglect and abuse so as to identify those at risk and refer them to appropriate agencies under the guidance of the Manager/Director. Demonstrates knowledge of crisis intervention theory.
- Facilitates or co–facilitates monthly support groups for IDT, and assists with the provision of a Bereavement Group support, as needed.
- Participates in weekly IDT meetings to provide ongoing updates, planning and revision of the POC as appropriate to patient/family changing needs and documented in biweekly updates. Participates in orientation, education, in-service training and QAPI [Quality Assurance Performance Improvement] program of Home Health.
- Provides consultation to other health professional personnel regarding psychosocial issues and provides in-service education as requested.
Documentation
- Clinical visit notes support the need formedical social services in light of the patient’s overall medical condition and experiences; the complexity of the services performed and the plan for the next visit based on the rationale of prior results.
- Initial assessment must be completed within 5 days of admission
- Completes documentation in accordance with agency timeliness policies.
- IDT notes completed timely including risk assessment and follow up plan
Qualifications
- Master's degree in Social Work (MSW) from an accredited school of social work.
- Holds a current LCSW, and is licensed to work in Massachusetts.
- Current Massachusetts Licensed Independent Clinical Social Worker (LICSW) preferred.
- Maintains an American Heart Association (AHA) CPR certification
- Minimum of 3 years of Medical Social Work experience.
- At least 1-year experience in Home Health care.