Archcare Social Work Coordinator in New York, New York
The social worker develops and maintains a therapeutic relationship with the participant to optimize participant functioning by providing quality services in conjunction with the interdisciplinary team. The social worker will conduct initial, sixth month and as necessary, face to face biopsychosocial assessments with each of the participant’s strengths and limitations. The social worker develops an individualized life plan with the participant identifying his or her goals and implementing interventions to assist with achieving their goals. The social worker always works within an interdisciplinary team, collaborates with team members and advocates for the participant when necessary. The social worker is expected to make home visits when necessary and communicates with supervisors and other team members when there is a change in mood and or behavior. The social worker assists with concrete services and helps the participant adjust to difficult life challenges such as medical conditions.
Assesses participants/family psychosocial status and social work needs utilizing professional knowledge, skills of observations and interviewing skills.
Assesses a member’s living condition/situation, cultural influences, and support systems to identify member’s strengths and deficits.
Assesses a member’s need for Daily Money Management annually and as needed.
Develops and implements the social work components and works with other team members to develop a comprehensive Interdisciplinary team plan of care based on the needs of participant and caregivers and goals mutually acceptable to the member/family and significant others
Monitors effectiveness and outcomes regularly and keeps the team informed as to participant progress and level of need. Remains alert to pertinent input from other team members, participants and family members/caregivers. Reviews and revises goals and approaches to member/ family care in coordination with interdisciplinary team members.
Provides initial face-to-face psychosocial assessments of new members enrolled in the program, and face-to-face reassessments at appropriate intervals according to PACE standards and the individualized needs of each participant
Provides ongoing assessments and services to identified participants/family, including emotional support/reassurance, assistance with community resource planning and crisis intervention.
Coordinates with the Entitlement Coordinator to ensure that entitlements and benefits are in place and recertified annually.
Provides advocacy to member/family, e.g., assistance in obtaining entitlements and community services.
Coordinates with the Primary Care team on obtaining of Advance Directives.
Assists participant with implementing a healthcare proxy and assists physician with encouraging participant to implement a MOLST. Assists when necessary with burial arrangements.
Educates and assesses participants/family understanding and ability to pay their Medicaid surplus payment, as appropriate.
Documents changes in the participant’s condition and details care provided by completing all required PACE documentation and ensuring compliance to Agency standards and policies.
Travels to patients’ homes and/or other facilities with varying environments as needed.
Manages social work planning for a caseload of participants. Maintains productivity sufficient to meet program goals.
Assists the interdisciplinary team members including the physician, as appropriate, in understanding the significant social and emotional factors related to the member’s health problems.
Utilizes appropriate community resources and serves as a liaison between the program and other community agencies.
Provides social work services in accordance with agency policies, practices, and procedures.
Assumes responsibility for continued professional growth, such as in-service programs
Participates in selected programs with community agencies.
Regularly informs the interdisciplinary team of the medical, functional, and psychosocial condition of each participant.
Remains alert to pertinent input from other team members, participants and caregivers.
Documents changes of a participant’s condition in the participant’s medical record consistent with documentation policies established by the medical director
Documents changes of a participant’s condition in the participant’s medical record consistent with documentation policies established by the medical director Participates in PACE and ARCHCARE SENIOR LIFE meetings including but not limited to, interdisciplinary team meetings, family meetings, staff meetings, in-service and training programs, rehab services meetings and Quality Improvement activities.
Maintains flexibility in schedule and responds to unexpected emergencies and changes in workload in order to fulfill responsibilities
Performs other related duties, as required
Meet a standardized set of competencies for the specific position description established by the PACE organization.
Minimum 1 year experience working with Geriatric population. Ability to read and write in English. Bilingual (Spanish) is a plus.
Master’s Degree in Social Work accredited by the Council on Social Work Education
Street: ArchCare Senior Life- Harlem
Shift Start Time: 8:30 AM
Shift End Time: 5:00 PM