1. Duties and Responsibilities:

·       Perform in-person initial assessments for enrollment of potential PACE Partners 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, which includes on call rotation for after hour collaboration or orchestration of patient needs. Schedule rotation to be determined with the Center Manager and Social Work team.

·       Act as liaison with participant, caregivers, and community agencies regarding orientation to and ongoing relations with Interdisciplinary Team, day center, and employees

·       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.

·       Work proactively to maintain participant housing through intervention with participant, caregivers, and housing

·     All other Duties as assigned.

1. Qualifications and Requirements:

Education/Training/Certifications

·       Master’s degree in Social Work from an accredited school of social work by the Council on Social Work Education

·       Member of the Academy of Certified Social Workers (ACSW) or other NASW- recognized certification preferred

·       Current driver’s license and proof of active auto insurance