Ensures quality delivery of social worker services and assists in providing home health care services that reflect the Agency’s philosophy and standards of home health care.
Responsibilities
Assists in evaluating referrals for admission to the home health program:
Assists in identifying patients who would benefit from services.
Acts as a resource person to hospital social service departments, nursing personnel, and discharge planners to evaluate referrals as appropriate.
Assists in investigating the patient’s financial situation as appropriate.
Assists in identifying patients’ needs and in formulating an initial plan of care for those patients admitted into the Agency’s service.
Assesses the patient, his/her family, support system, and home situation, and identifies needs or potential needs.
Works with the nurses or other health team members and formulates a comprehensive plan of care to meet the patients’ needs.
Explores available community resources that might be helpful in meeting the patients’ needs.
Explores available community resources and assists patient in qualifying for eligible programs.
Assists patients in utilizing any resources that are available to obtain maximum benefit from the program.
Follows up Adult Protective Services referrals with letters to the Department of Social Services directors.
Counsels and supports patients.
Assists patients in utilizing or building support systems.
Assists patients and their families in dealing with the emotional aspects of their illnesses and conditions.
Assists patients and their families in accepting their medical condition and complying with medical recommendations.
Provides assistance to patients in formulating Advance Directives.
Participates in multi-disciplinary team meetings.
Reevaluates goals and plans of care and offers suggestions to meet patients’ needs in a better way.
Assists health team members with emotional factors related to patients’ health problems.
Acts as a resource person for health team members in planning patient care and offers suggestions as appropriate.
Maintains required medical records.
Documents observations made, and actions taken in a timely fashion using paper or electronic means.
Documents patients’ progress or response to care as appropriate using paper or electronic means.
Keeps physicians informed of patients’ progress.
Forwards appropriate documentation concerning patients’ progress and summary of care to physicians at regular intervals.
Discussed patients with physicians when appropriate to clarify goals and objectives and to clarify the plan of care.
Performs other duties as assigned by management.
Qualifications
Holds Master’s degree from school of social work accredited by the Council on Social Work Education.
Holds active state social work license.
Has minimum of one-year experience as a social worker in a hospital, out-patient, nursing home, or home care setting.
