Geriatric Social Worker II

Key Responsibilities

• Conducting in-home geriatric assessments in collaboration with a GRACE Nurse Practitioner.
• Developing and implementing individualized care plans using GRACE care protocols.
• Engaging patients and caregivers in psychosocial support, health education, and goals-of-care discussions.
• Coordinating care with primary care providers and the GRACE interdisciplinary team to optimize outcomes and reduce unnecessary hospital utilization.
• Screening/Assessment: Provide initial and ongoing assessment of an individual's psychosocial needs, including depression screen, cognitive impairment screen, review of financial status and health care benefits, home safety evaluation, review of social supports, and assessment of caregiver burden.
• Treatment Planning/Goal Setting: Develop and implement a comprehensive treatment plan of care with the older adult based on the assessment, working with the GRACE Interdisciplinary Team.
• Care Plan Development: Work with the GRACE Nurse Practitioner and GRACE Interdisciplinary Team to develop a care plan and communicate that plan to the patient, caregiver, and the primary care provider.
• Education/Health Promotion: Provide education about community resources, entitlement programs, health care benefits and Advance Directives/Living Wills.
• Advocacy: Advocate for older adults to ensure that they have access to all needed care and resources within the community.
• Collaboration: Work to create an atmosphere in which social workers build professional relationships with peers and colleagues in the GRACE Interdisciplinary Team.
• Supportive Counseling: Provide the individual and his or her family/caregivers with supportive counseling as needed.
• Crisis Intervention: Assess and intervene in any medical or psychiatric crises presented by the individual and participate in developing crisis management and safety plans.
• Non-Patient Care Responsibilities: Enter all patient/family contacts in the electronic record using appropriate formats and templates.

Qualifications

• Master of Social Work (MSW) from an accredited school of Social Work required.
• Driver's License required.
• 2+ years of clinical experience in a medical setting required.
• 1+ years' experience with geriatric patient population strongly preferred.
• Clinical licensure (LCSW, LICSW or LMHC) preferred.

Additional Knowledge, Skills and Abilities

• Demonstrates proficient clinical judgment and application of professional values and ethics.
• Demonstrates proficiency to formulate assessment of risks, crisis intervention, psychosocial assessments, treatment plans, and the documentation of both in a timely manner.
• Demonstrates sound clinical judgment and innovation in advocating for clients while maintaining professional boundaries.
• Demonstrates proficient working knowledge of internal and external resources and refers appropriately.
• Provides a range of evidence-based interventions.
• Ability to advocate, coordinate, and continuously communicate with treatment plans with patients, family and the interdisciplinary team.
• Incorporates social sensitivity.
• If appropriate, utilizes supervision and consultation regularly and appropriately.
• Actively seeks assistance with complex cases and situations in a timely manner.
• Engages in quality improvement projects, uses data to measure progress.
• Facilitate skill-based groups.
• Knowledge, understanding and ability to negotiate and work in a complex organization.
• Demonstrate capacity to effectively communicate findings with a broader audience.