Under the supervision of the Center Director, the Social Worker plans, organizes, and implements social work services for PACE participants and their families. Responsibilities include, but are not limited to, conducting participant social work assessments and treatment, as well as providing education and counseling to participants, caregivers, and other appropriate representatives or family members to help maintain participant support within the community. The Social Worker serves as a liaison among the interdisciplinary team, caregiver representatives, and community agencies.

Qualifications and Requirements:

Education/Training/Certifications:

• Masters degree in social work from an accredited school of social work
• Member of the Academy of Certified Social Workers (ACSW) or other NASW-recognized certification preferred
• Current drivers license and proof of auto insurance
• Licensed by the California Board of Social Work Examiners and shall comply with the Social Workers' Licensing Act of 1991

Experience:

• Two (2) years of experience working on an interdisciplinary team in a hospital, nursing home or community-based setting is preferable.

Duties and Responsibilities:

• Conduct in person initial, scheduled, and unscheduled reassessments per policies.
• Collaborate with the interdisciplinary team to develop a comprehensive care plan for each participant.
• Maintain regular attendance at and participate in daily Interdisciplinary Team meetings, communicate participant changes and collaborate with team members in care planning decisions and coordination for 24-hour care delivery.
• Act as the liaison between the interdisciplinary team, caregiver representatives, and community agencies. Assist with locating resources
• Assess mental health needs.
• Provide ongoing support, counseling, and education to participants and caregivers regarding a variety of issues, including but not limited to: the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics and changing roles, PACE model and PACE health services.
• Work proactively to maintain participant housing through intervention with participant, caregivers, and housing. Provide referrals to subsidized housing and assisted living residences including, completing applications, obtaining medical records, accompanying participants to interview assessments and tours if participant has no other support systems or to assist caregivers.
• Assist participants to function at the most independent community level possible.
• In collaboration with other members of the Interdisciplinary Team, coordinate admission/discharge to contracted facilities for temporary respites and permanent placement.
• Perform home visits as needed to assess living environment and support system.
• Perform visits at hospital within 24 hours of admission or on Monday if the participant is admitted on Friday or weekend. Coordinate hospital discharges in conjunction with PACE primary care providers and interdisciplinary team Communicate with family or caregivers frequently and as needed to update on discharge plans.
• If end of life care is appropriate, actively provide emotional support, grief counseling, education, and funeral/financial planning referral. Facilitate end of life or nursing home placement as needed.
• On an annual basis present the written participant rights documentation to participant and/or caregiver. In the event the participant is unable to understand the information, the social worker will ensure the caregiver or designated representative understands the participant rights. If there is a language barrier, the Social Worker will use an interpreter.
• Initiate referrals to external resources with community agencies such as Adult Protective Services, Housing Authority, or public utility companies. Advocate for participants with these entities for purposes of maintaining community stability.
• Assist participants with Social Security Income (SSI) and Social Security Disability Insurance (SSDI) application process as needed.
• In collaboration with the primary care provider, assist participants and caregivers to complete Medical Durable Power of Attorney (MDPOA), Proxy, and Do Not Resuscitate (DNR) directives as needed.
• Assist participants and family in keeping resources within guidelines for Medicaid eligibility and assistance if needed with annual Medicaid application.
• Attend and actively participate in a variety of organizational meetings related to participant care or daily operations, in-services, and community agency meetings.
• Act as a resource to other team members and day center staff regarding topics such as dementia, difficult behaviors, and difficult personalities.
• Complete all documentation of services and interventions in participants medical records
  
• Assist participants disenrolling from PACE in coordinating insurance and referrals for other community or facility-based services as desired by the participant.
• In the event of termination of enrollment in K-day PACE, the social worker will act to coordinate the transitional care necessary to ensure continuation of care during and after termination. Assist participants in obtaining reinstatement in conventional Medicare and Medicaid benefits, transition to other care providers, make referrals to other community-based or facility-based providers, assist in providing the participants medical records to new providers with participant approvals.
• Act only within the scope of his or her authority to practice.
• Follow all Policies and Procedures and OSHA safety guidelines.
• Protect privacy and maintain confidentiality per HIPAA regulations of all company procedures, results and information about employees, participants, and families.
• Practice standard precautions.
• Maintain a safe working environment, following PACE safety policies and procedures.
• Participate in and support Quality Improvement initiatives
• Participate in continuing education classes and any required staff and training meetings.
• Maintain professional affiliations, required certifications and continuing education requirements.