Job Description: IntroductionAt EverTrue, team members at all levels find their calling in our mission of Older Adults Living Life to the Fullest. In this work environment, all team members are part of a community and appreciated by the people they work with – residents and coworkers – every day. SummaryProvides general medical social work services / care management to the Anywhere Care patient population, facilitates communication between patients, patient families, and staff, establishes and/or facilitates cooperation and services between the Agency and the community at large, explores the potential for new services and assists with the development of expanded services.Responsibilities1.Manages intake and new referrals as needed to efficiently connect prospective patient/clients to appropriate service line2.Provides social work services to the assigned client and family3.Completes required evaluations/assessments to determine the client’s need for care and services4.Assesses the relationship of the patient’s medical and nursing requirements to the patient’s home situation, overall health, cognitive status, spiritual wellness, emotional wellness, financial resources, and access to community resources5.Assesses caregiver’s ability to function adequately; Assesses special needs related to cultural diversity including communication, space, role of family members and special traditions6.Assesses the patient/family psychosocial status, potential for risk of suicide and/or abuse or neglect; Identifies family dynamics and communication patterns7.Takes appropriate action to link patients to appropriate community resources to assist in enhancing the client’s overall wellness and quality of life8.Serves as liaison between patients or families and community agencies9.Provides counseling services, as appropriate, and support and consultation to the client’s family member or caregiver on a short-term basis or as needed10.Assists the physician and other IDT/IDG members in recognizing and understanding the social/mental stress and/or disorder that exacerbates the symptoms related to disease management/terminal illness11.Participates in the development and revision of the plan of care and provides all care according to physician orders.  Involves the patient/family in the plan of care.  Assesses environmental resources and obstacles to maintaining safety12.Identifies and utilizes appropriate community resources and assesses patient/family ability to access them13.Educates patients and families related to social service issues, which may include long-term placement, financial issues, and funeral planning14.Identifies support systems available to reduce stress and facilitate coping with disease progression and/or end-of-life care15.Utilizes the medical record software system via laptop or agency desktop for patient documentation; Initiates documentation in the patient’s home on the laptop and completes after the visit16.Prepares clinical and progress notes; Submits notes according to agency policy17.Evaluates for long-term care when appropriate and assesses patient/caregiver ability to accept change in level of care; Communicates psychosocial information to inpatient facility when level of care is changed18.Participates in discharge planning; Identifies patient/family needs when discharged or when level of care changes19.Participates in client care conferences as needed20.Performs within their recognized scope of practice21.Supervises BSW/MSW student interns as needed22.Represents EverTrue Anywhere Care programs and participates in community outreach by participating in community task forces or workgroups associated with Anywhere Care services, presenting to local organizations about Anywhere Care services  23.Supports data management/reporting responsibilities as assigned.24.Participates in on-call duties as assigned and defined in the On-Call PolicyQualifications, Knowledge, Skills &amp; AbilitiesTo perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required. <ul><li>MSW from an accredited school of Social Work</li><li>A current license in the state of practice (if required), with one-year social work experience in a health care setting.</li><li>Prefer experience with Medicare programs and participation in community agency activities.</li><li>Demonstrate basic knowledge of all procedures included in the social worker job description.</li><li>Must have the ability to follow instructions from physicians, nursing supervisors and other professional staff.</li><li>Ability to communicate effectively with managers, patients, families and co-workers.</li><li>Must be able to assess safety of home situations for self, patients, and other staff members, including physical and psychological dangers.</li><li>Must have the ability to effectively cope with patients, families and all others with varying backgrounds, socioeconomic conditions, and value judgments.</li><li>Must be assessed by an LCSW for clinical competency upon hire and annually</li><li>Must have computer and excellent communication skills.  Maintains confidentiality of information relating to the patient and family. Will discuss only those aspects necessary to the care and treatment of patient and family with those directly involved in the patient’s care.</li></ul>Physical Requirements and Working ConditionsThe physical activities and demands described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job duties and responsibilities.While performing the duties of this job, the employee is regularly required to sit; reach with hands and arms.Travels out in the community that allows for exposure to weather conditions and potential for unsafe environments.This job description in no way states or implies that these are the only duties to be performed by the employee occupying this position.  Employees may be required to follow other job-related instructions and to perform other job-related duties as requested, subject to all applicable federal, state, and local laws and standards.  Certain job functions described herein may be subject to possible modification in accordance with applicable federal, state, and local laws and standards. <div>EverTrue Pay &amp; BenefitsPay grade(s):For job profile 299: Grade D, $57,000.00 to $91,000.00. Eligible for shift differentials: No.For job profile 298: Grade D1, $27.40/hour to $43.75/hour. Eligible for shift differentials: No.For information on EverTrue benefits-eligibility by employment status, please see below.All employees: Paid Time Off (PTO) and PTO Sell-back, Retirement savings benefits with an employer match contribution, Education Financial Assistance, Employee Assistance Program (EAP), Wellness, Pay advances (PayActiv), Caregiver support (TCARE), Leaves of Absence, Special retail deals and discounts (Perkspot), and Commuter support.Part-time: In addition to the benefits provided to all employees… Extended Sick Pay, Bereavement Pay, and Jury Duty Pay.Full-time or Weekend Option: In addition to the benefits provided to all employees and Part-time employees… Medical/Pharmacy, Dental, Vision, Flexible Spending Accounts (Healthcare and Dependent Care), Life insurance, Disability (Long-term and Short-term), Voya income protection benefits (Hospital, Critical Illness, and Accident), and Pet insurance.</div>Additional Information:N/A

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Lutheran Senior Services

EverTrue is dedicated to helping older adults live life to the fullest. We seek a full-time Home Health MSW with an accredited MSW degree and state license. You will provide social work services, care management, and community resource linkage for patients and families. We offer PTO, retirement match, education assistance, wellness programs, and comprehensive insurance benefits.

Home Health Medical Social Worker

Summary