McPherson, Kansas
Social Work Director, LMSW Job Opening in McPherson, Kansas - Job Title: Master of Social Work
Reports To: Center Director
Department: Social Work
Status: Exempt
Location: Bluestem PACE
FT/PT: Fulltime
Bluestem PACE
Position Overview:
Under the supervision of the Center Director plans, organizes and implements social work services for PACE participants and families. Responsibilities include but are not limited to: participant social work assessment; treatment; and teaching and counseling of participant, caregiver or other appropriate to maintain participant support in the community. Social Worker interventions may also include: individual participant contacts; appropriate collateral contact; participant and family education, assessment, and counseling; assistance with locating resources; addressing mental health needs as they arise; ongoing case management; advocacy to ensure participant and caregiver needs are met and addressed; and disenrollment procedures. The Social Worker is the liaison between the interdisciplinary team, caregiver representatives, and community agencies.
Essential Job Functions:
Physical Demands and Working Conditions:
The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. In compliance with ADA requirements, reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.
Work Environment: Employee must be able to work effectively within an interdisciplinary team model, interfacing and collaborating with a wide range of clinical and social services disciplines who work together to manage the PACE participants' care. The work setting is in an Adult Day Health Center and primary care clinic environment with moderate noise levels and controlled temperatures.
Physical Requirements: Requires manual and finger dexterity and eye-hand coordination; the ability to use department equipment; and the ability to lift/carry up to 30 pounds using appropriate body mechanics with reasonable accommodation if needed.
Visual, Hearing and Communication Requirements: Requires corrected vision and hearing to normal range, with or without reasonable accommodation. Ability to communicate by way of the telephone with participants, customers, vendors and staff.
Pressure Factor: Requires working under stressful conditions. Working conditions may be noisy and crowded and fluctuating indoor temperatures. Moderate pressure to meet scheduled deadlines. Potential for exposure to verbal aggression by client, vendors, and staff.
Environmental Conditions: May be exposed to a risk of bodily injury through contact with toxic substances, medicinal preparations, bodily fluids, communicable diseases and any other conditions common in a healthcare environment. Subject to unpleasant odors.
Duties and Responsibilities:
Perform in-person initial assessments for enrollment of potential PACE participants to obtain a complete psycho-social history, to include: descriptions of cognitive status, social supports, family dynamics, mental health and substance dependency, and other current issues and needs.
Collaborate with the interdisciplinary team to develop a comprehensive care plan for each participant.
Conduct in person reassessments of enrolled participants every six months and as needed when participants? conditions change.
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 liaison with participant, caregivers, and community agencies regarding orientation to and ongoing relations with Interdisciplinary Team, day center, and other PACE staff.
On an annual basis (during annual or semiannual reassessment) presents the written participant rights documentation to assigned participants and or caregiver. In the event the participant is unable to understand the information, the social worker will ensure the caregiver or representative understands the participant rights. If there is a language barrier, the Social Worker will use an interpreter.
Provide ongoing support, counseling, and education to participants and family 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.
Assist participant to function at most independent community level possible.
Present requests to Interdisciplinary Team for and coordinate admission/discharge to contracted facilities for temporary respites and permanent placement.
Perform home visits quarterly, or as needed, to assess living environment and support system.
Act as facilitator for meetings with participant, family, caregivers, and community agencies to clarify or problem solve issues, including plan of care. Mediate discussions between all parties.
Provide referrals to subsidized housing and assisted living residences. This may involve completing applications, obtaining medical records, accompanying participants to interview assessments and tours if participant has no other support systems.
Perform visits at hospital within 24 hours of admission or on Monday if participant is admitted on Friday or weekend. Coordinate hospital discharges in conjunction with interdisciplinary team and communication with attending physician. Communicate with family or caregivers frequently and as needed to update.
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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.
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 and caregivers to complete Medical Durable Power of Attorney (MDPOA), Proxy, and Do Not Resuscitate (DNR) directives as needed.
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 clinical service in participants? medical records, including: initial assessments; reassessments; change of status; temporary or permanent placements; hospital admissions and discharges; home and nursing home visits; and other significant events according to PACE documentation requirements.
Assist participants with Social Security Income (SSI) and Social Security Disability Insurance (SSDI) application process as needed.
Assist participants and caregivers in filing grievances and appeals.
Assist participants and family in keeping resources within guidelines for Medicaid eligibility and assistance if needed with annual Medicaid application.
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 Bluestem 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 participant?s 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 of all company procedures, results and information about employees, participants, and families.
Practices standard precautions.
Maintain safe working environment, following PACE safety policies and procedures.
Participate in and support Quality Improvement initiatives
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Participate in continuing education classes and any required staff and training meetings.
Maintain professional affiliations, required certifications and continuing education and Requirements:
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Master?s degree in Social Work from an accredited school of social work
Current driver?s license and proof of auto insurance
Licensed by the Kansas 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.
Minimum of 1 year working with a frail or elderly population.
Skills and Knowledge:
Familiarity with the psycho-social issues of the frail and chronically ill and their caregivers.
Ability to provide psychosocial assessment and individual, family and group counseling.
Ability to maintain accurate records and to prepare clear and concise reports, correspondence and other written materials.
Good public speaking skills with all size groups.
Effective verbal and written communication skills.
Demonstrated ability to work in an interdisciplinary team setting.
Computer literacy.
Medical Clearance:
Employees must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.
Employees must comply with Bluestem PACE Influenza Immunization Policy.
Competency:
Position specific competencies for the Social Worker will be met prior to assuming participant care.
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Job Type: Full-time
Required education:
Master's
Required experience:
Social Work: 2 years
Required license or certification:
LMSW
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