Performs psychosocial assessments of patients and families and develops and implements an appropriate Social Work treatment plan. Identifies unmet psychosocial and concrete service needs and develops plans to meet these needs as part of a coordinated Home Care plan. Explores available community resources based on identified patient needs. Explores patients' financial resources and assists with planning related to identifying limitations and/or deficits.
1.Performs psychosocial assessment of patients and families in the home setting and formulates and implements a physician-directed treatment plan.
Reviews Home Care referrals in relation to Social Work for completion and appropriateness of the plan of care with the nurse coordinator and initiates Social Work services.
Discusses the results of the evaluation with the nurse coordinator, patient, and patient's significant others.
Utilizes thorough and appropriate evaluation techniques to establish goals.
Designs and implements a treatment plan that best meets the needs of the patient and works toward achieving established goals.
Evaluates the effectiveness of treatment on an ongoing basis and modifies plan, as needed.
Collaborates with other staff involved in patient's care to enhance the integration of services.
Confers with the nurse coordinator to discuss patient's response to interventions.
Review's patient's status.
Evaluates patient and/or family knowledge and understanding of condition and treatment plan as it relates to family dynamics and patient's progress.
2.Provides short term counseling aimed at facilitating patient adjustment.
Utilizes knowledge of individual psychosocial development, family structure and culture values.
Utilizes knowledge of the patient's medical problems, his/her predicted course and relationship to psychosocial functions.
Counsels individuals and families dealing with illness.
Contributes to the understanding by the health care team of the social and emotional elements of the patient's life that relate to the illness.
3.Explores appropriate community resources as part of the Social Work component of the comprehensive treatment plan.
Obtains information relative to patient as a total individual within the framework of his/her social or economical environment.
Develops and expands knowledge of available community resources and demonstrates the ability to facilitate referrals.
Assists patients and families in understanding and negotiating community resources, including, but not limited to, HEAP, Food Stamp Program, etc.
Functions as a resource to Home Care staff regarding available community services.
Evaluates the patient's knowledge, understanding and ability to follow through with referrals.
Offers guidance and assistance with services as required.
4.Submits required documentation in accordance with the policies and procedures of North Shore Home Care.
Prepares a report of patient's status for Home Care following an initial home visit including the nature and extent of the patient's psychosocial, financial and emotional problems and a clear statement of goals.
Completes documentation reflecting treatment and responses to treatment.
Submits progress notes to the Agency for review after home visits.
5.Participates in educational activities as indicated and whenever possible including, but not limited to presentations, community speaking, conferences, workshops, seminars.
6.Performs related duties, as required.
Master's Degree in Social Work, required.
LMSW required within one (1) year of employment.
Clinical experience, preferred.
Current valid NY State Driver's license.