Home Health Comfort Care Social Worker

GENERAL DESCRIPTION:

Under the supervision of the Comfort Care Supervisor / HH Nursing Supervisor, the Comfort Care Social Worker (case manager) is responsible for providing outreach, social services, crisis counseling, grief counseling and intervention, advocacy, and case management to participants enrolled in the program and their families.

RESPONSIBILITIES:

1. Provides case management services, crisis counseling, and grief counseling to an assigned caseload of comfort care participants. The SW will be involved in the provision of end-of life care to participants and their families.

2. Provides psychosocial education to participants and family caregivers about coping skills, comfort care philosophy, and nonpharmacological symptom management strategies.

3. Conducts and completes initial social services assessments and develops corresponding treatment plans within ten (10) working days of the participant’s enrollment in comfort care.

4. Completes routine re-assessments and plans of care for each participant by the scheduled Interval Assessment (IA)date; completes re-assessments and plans of care within seventytwo (72) hours of participant’s or family’s request.

5. Participates as an integral member of the multidisciplinary team to develop/coordinate a comprehensive plan of care for comfort care participants.

6. Communicates participant condition or status changes to the IDT at IA meetings or at the daily participant Plan of Care meetings as expeditiously as required by the participant’s condition.

7. Serves as a liaison with the participant’s family via home visits, family conferences and telephone contacts, utilizing the appropriate approach to keep all parties informed.

8. Establishes and maintains a positive relationship with Long-Term Care Facilities in order to ensure that when participants need placement, their needs will be met appropriately and on a timely basis.

9. Assist in training/supervision of social work interns (students), coordinating their assignments with the Comfort Care Supervisor / HH Nursing Supervisor.

10. The SW will serve as a liaison and advocate for participants and their families with agencies such as Social Security, TDHHS, Housing Authority, Adult Protective Services, etc.

11. The SW will provide appropriate documentation for internal and external reporting purposes: i.e., psychosocial assessments, progress notes, reports of changes in status/condition, etc.

12. The SW will perform on-call duties from Friday to Friday, reporting to the PCP on-call, and any other staff person who is on call during the same time. SW will cooperate with other disciplines to trouble-shoot and resolve difficulties that arise while performing on call duties.

13. SW will complete mandatory initial and ongoing training hours as scheduled

14. SW will be personally responsible for maintaining current SW licensure and training hours as required by the Texas State Board of SW Examiners.

15. Other duties as assigned by the Comfort Care Supervisor / HH Nursing Supervisor.

Required Experience

QUALIFICATIONS/REQUIREMENTS:

1. A graduate of an accredited university with a Master’s degree in Social Work field, and licensed by the Texas State Board of Social Worker Examiners.

2. One year experience in providing Social Services to a frail or elderly population.

3. Experience in working with comfort care or end of life participants preferred.

4. Knowledge of community referral system for community services.

5. May have a Clinical Social Worker licensure.

6. Has excellent presentation skill to be able to present End of Life services available at Bienvivir to participants, Bienvivir staff, and community groups.

7. Works well within the ethical principles of the Social Work Code of Ethics, and exhibits excellent communication skills when interacting with participants, caregivers, and colleagues.

8. Bilingual in English and Spanish.

9. Must have dependable transportation, valid driver’s license, and automobile liability insurance.