Provide a psychosocial perspective to the interdisciplinary evaluation, assessment, plan of care, ongoing services, and disenrollment processes of the PACE program. Interventions may include individual participant and/or family contacts, collateral contacts, participant and family education, assessment, and counseling; mobilization of resources; identification and management of behavioral health needs; case management and advocacy; and discharge planning. Use knowledge of social systems and individual behavior to skillfully apply interventions that meet the unique needs of PACE participants and their families. The MSW collaborates as part of the Interdisciplinary Team in efforts to optimize health status and quality of life of the PACE participants.
- Implement a person-centered approach in the completion of all scheduled and unscheduled psychosocial assessments as required or assigned.
- Engage participant, family members, and/or caregivers to identify participant's health goals and expectations.
- Identify risk factors impacting overall health, and work to mitigate the effects of those for improved functioning and quality of life.
- Collaborate with IDT members in the design and implementation of individual care plans - by contributing the profession's unique perspective in identifying and addressing participant needs.
- Attend and actively participate in all IDT and Care Coordination meetings.
- Facilitate family conferences to address participant/family needs and to facilitate communication with the IDT.
- Develop and implement therapeutic support groups, address individual counseling needs, as well as crisis intervention as needs arise.
- Coordinate the completion of advance life planning documents in cooperation with the PCP, family/caregivers, as applicable.
- Maintain current information about and create linkage to appropriate community resources (ex. housing, support groups, financial assistance, legal aid, mental health support, etc.) for ongoing advocacy.
- Complete documentation in medical chart in a timely manner and as required.
- Keep up-to-date on changing rules and regulations of entitlement programs and facilitate communication with governmental agencies such as Medi- Cal, Medicare, and Social Security.
- Participate in home visits as deemed necessary by IDT.
- Conduct discharge planning to promote continuity of care in the event of disenrollment.
- Consistently adhere to Social Work Code of Ethics, maintain confidentiality, and strive towards service excellence.
- Attend all team and staff meetings, Participant Council Meetings, or other meetings as assigned.
- Continue professional development through engagement in educational opportunities to promote the maintenance and improvement of professional competence.
- Other duties as assigned.
- Master's Degree in Social Work (MSW) from an accredited university is required.
- Two or more years' experience in case management, social advocacy, and/or mental health - with the geriatric population.
- Field work/internship may substitute 1 year of experience.
- Bilingual: Spanish/English, Chinese/English or another second language is strongly preferred.
- CPR/First Aid certificate is required