Job Description

The Medical Social Worker at On Lok PACE at the Institute on Aging (IOA) provides psychosocial assessment and therapeutic counseling to a caseload of clients with complex medical and psychosocial problems. The Medical Social Worker serves as the primary liaison between participants, family members, and the interdisciplinary care team. Conducts in-depth biopsychosocial assessments to determine participant needs across multiple domains, encompassing physical and mental health, financial, and environmental issues. Utilizes evidence-informed interventions to solicit participant goals, and develops and initiates a participant-centered care plan that integrates with the IDT. Joins Primary Care Providers and Registered Nurses to form a core primary care team for each participant and directs the involvement of other health care disciplines on the IDT. Develops a rapport and maintains a care management relationship with participants and members of their support system as appropriate. Partners with the assigned Care Manager and other IDT members to coordinate care for participants with complex needs who require multiple services over time, and to monitor transitions of care and ensure safe discharge planning. Provides supportive counseling to assist participants in coping with illness, grief, and loss. Provides crisis intervention, advocacy, problem solving, and appropriate therapeutic interventions. Facilitates family and care team meetings to ensure alignment and promote decision-making around end-of-life planning, health care wishes, and goals of care. Cultivates relationships and partnerships with community providers that support and extend social work interventions. Facilitates the enrollment of On Lok PACE participants at IOA in partnership with the On Lok PACE enrollment team. Fulfills an advocacy role, when necessary, within the interdisciplinary setting and within community programs related to ongoing management of mental health, co-occurring substance abuse issues, and chronic issues of unstable housing. Facilitates behavioral health referrals and helps monitor efficacy of behavioral health interventions. Consistent with program guidelines, meets regularly with participants to review progress on plan of care goals and modifies as needed. Documents all service delivery and encounters in the participant’s electronic health record (EHR) according to program and department standards. Educates participants and their support system about available resources to support their needs, assists in making connections, and offers psychosocial education to encourage self-management of needs. Establishes and maintains open and effective communication with the IDT and other involved community providers. Provides appropriate information on all significant aspects of individual participant care and program operations, while maintaining appropriate confidentiality. Working closely with other disciplines and health professionals, continuously evaluates and promotes the participants’ ability to remain safely in the community, and coordinates facility placement if/when necessary. Participates in quality improvement studies and data collection, as required. Attends and actively participates in IDT and program meetings, activities and problem-solving endeavors; contributes to open lines of communication within the team. Recognizes clinical or personal limitations by utilizing supervision, when necessary. Understands and applies the regulatory and procedural requirements of the social work discipline within PACE as well as the policies and procedures of the Institute on Aging. Remains current in the field of professional social work by attending continuing education classes and/or Inservice training to increase knowledge, skills and attitudes related to medical social work, social work core competencies, case management, gerontology, family and community systems and other areas relevant to the Institute on Aging participant population. Participates in and promotes ongoing efforts towards continuous quality improvement initiatives and Service Utilization Reviews. Actively incorporates the ethical standards of the National Association of Social Workers and upholds the core values including: service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence. All other reasonably related responsibilities as assigned. Requirements include holding an MSW from an accredited school of Social Work, at least one year of professional experience working with frail elderly, and at least one year of experience working in an interdisciplinary care model. Licensure is not required but supervision toward LCSW licensure is provided. Background and experience with medical and psychosocial problems of functionally impaired adults and the frail elderly, exceptional communication and presentation skills, detail orientation, computer literacy preferred, bilingual Cantonese or Spanish preferred. The Institute on Aging reserves the right to revise job descriptions or work hours as required.

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