Location: Flushing, Queens, New York

Pay: Up to $39/hour depending on experience

Job Type: Temp - 3 month assignment covering for leave. 

Requirements: MSW, LMSW or LCSW, 1 year of working with Elderly population. 

 

Job Summary: 

Under the direction of the Social Work Manager, the Social Worker will provide social work services including: advocating, assessing, assisting, collaborating, educating, evaluating, implementing and planning for participants in various aspects of the participant's life including but not limited to psychological, psychosocial, financial, environmental, and interpersonal matters. Social work engagement takes place in various settings including but not limited to the participant's home, PACE site, community settings (hospital, SNF, ALF, etc.). 

 

The Social Worker will serve as a conduit among the participant/authorized representative, the Interdisciplinary Care Team and other community agencies (hospital, SNF, ALF, APS etc.) to ensure the highest level of satisfaction throughout the PACE lifecycle. The Social Worker will provide support to the PACE participant, including but not limited to concrete services, adjustment to illness/disability/treatment, crisis intervention, and end of life care. The Social Worker will assess and evaluate psychosocial functioning; conduct mental status assessments; participate in discharge planning; and enlist collateral community agencies’ services as applicable.

 

Provide ongoing social work services to participants and their authorized representatives to help them understand and follow care delivery recommendations; to assist them with personal and environmental challenges which predispose toward illness or interfere with obtaining maximum benefit from the PACE program.

 

Educate participants and their authorized representatives in understanding and using community, health and public services and benefits which help them remain safely in the community (SNAP, SC/DRIE, Medicaid, Medicare, housing, etc.) and assist with making referrals, coordinating services and completing related documents as needed.

Ensure timely and appropriate communication and coordination of care during/post hospitalization, or other inpatient stay, to ensure that a participant's wishes regarding his/her care are followed during that admission. All communication with facilities, hospital/STR, will be reported to the IDT and documented.

Ensure telephonic outreach is made within 24-48 hours of hospitalization, and regularly thereafter during admission, to provide support to the participant, to coordinate with the hospital clinical team to discuss participant's treatment plan, and to assist in discharge plan coordination with the PACE IDT. The Social Worker will also conduct a visit to the participant within 72 hours of discharge (business days) to assess for any psychosocial issues that may contribute to re-hospitalization.

Provide social work consultation to participants and authorized representatives as indicated. Provide education on treatment options, including palliative and end of life care, and help coordinate services. Arrange bereavement assistance, supportive counseling, or other behavioral health services as needed. Provide caregiver support as needed.

Complete biopsychosocial assessments (semi-annual, quarterly revisit, PRN, SOC, ROC, SCIC, SDR), cognitive/emotional status assessments (i.e. GDS, SPMSQ) and other assessments as applicable. Complete HCP document and facilitate completion of advance directives, such as the DNR/DNI/DNH/MOLST documents.

Assure participant-focused Care Plan psychosocial goals and interventions are applied.

 

Other duties as assigned. 

Education: M.S.W. from an accredited college or university.

License: LMSW or LCSW required. Must have active NY State Social Work license.

Experience:
One (1) year experience in a health care setting.

Minimum of one (1) year of experience working with a frail or elderly population or, if the individual has less than one (1) year of experience but meets all other requirements, must receive appropriate training from the PACE organization on working with a frail or elderly population upon hiring.

Experience in home care and/or field work is preferred.

Regular access to a car for field visits is preferred but not required.