• Performs initial assessments of PACE participants to obtain a psychosocial history including cognitive status, mental health and substance use history, behavioral concerns, family dynamics, and current social supports.
• Participates within the interdisciplinary team in the formulation of Plans of Care, as well as in other interdisciplinary team settings that plan, coordinate and monitor the care of program participants.
• Conducts in-person reassessments of enrolled participants every six months or as determined by policy and best practice. Assessments include collaboration with caregivers and assessment of housing risk.
• Develops collaborative relationships with internal and external partners. Utilizes a solution-oriented perspective to facilitate resolution of participant needs.
• Acts as a primary liaison between the participant/family and the IDT to facilitate communication.
• Facilitates, mediates and documents participant care conferences, family meetings and facility partnership meetings.
• Monitors changes in the patient's condition and needs.
• Assists physician, or intermediate care provider, and other team members in understanding the significant social and emotional factors related to the health problems.
• Provides psychosocial services in accordance with established standards.
• Must have Master’s degree in Social Work from a school of social work accredited by the Council on Social Work Education
• Current CPR certification or the ability to obtain CPR certification is required.
• One year experience in a health care setting
• Experience conducting psychosocial assessments, care planning and case management skills required.
• A minimum of one year experience working with the frail or elderly.
• Must be computer proficient and possess experience with Microsoft Word, Excel, and Outlook.
• Ability to read, analyze and interpret regulations and other documents.
• Strong interpersonal skills and ability to effectively and tactfully present information to, and communicate with, co-workers, employees, and others.
• Ability to define problems, collects data, establish facts, and draw valid conclusions.
• Able to establish and maintain cooperative and positive working relationships