Hartford HealthCare at Home
Mansfield Center, CT
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DescriptionJob Schedule: Full Time
The Home Care Social Worker (LMSW) is a Master’s prepared, Licensed Clinician who will engage patients, in their home, to determine their short and long-term needs, and will provide short-term counseling/interventions to meet care plan objectives. The Home Care Social Worker will collaborate with patients, their families, physicians, and home care team to identify and address patient’s bio-psychosocial needs, barriers to care, risk-factors, etc. The Home Care Social Worker is familiar working with patients who have complex health care and psychosocial problems that require a high degree of clinical oversight and creative problem solving. The Home Care Social Worker works independently and uses critical thinking skills to make accurate, and at times, quick judgments, and has the ability to respond appropriately to crisis situations.
Key areas of responsibility
Collaborates with the interdisciplinary team regarding patients that were identified for Social Work Services, and through IDT/case communication, assists with identifying patients that would benefit from Social Work Services.
Completes comprehensive in-home psychosocial evaluations. Evaluations include:
Consideration of developmental, social and/or cultural, substance abuse, psychological, environmental, and medical issues
Physical, social, emotional, and familial characteristics
Use of evidence-based assessment tools to determine cognitive status and behavioral health needs including Dementia, Depression, Anxiety, etc.
Home safety, family dynamics, caregiver strain, and other risk factors including suicide
Patient/family understanding of their disease treatment options
Strengths, available supports, and barriers to care
Determine appropriate level of care including needs for long/short-term skilled-nursing facilities, assisted living facilities, adult day care, etc.
Based on a comprehensive, culturally competent assessment collaborates with the patient and family to create a care plan with measureable goals. Implements short-term interventions to address identified barriers and promote health and well-being.
Provides clinical treatment services in form of triage, crisis intervention, individual or family therapy, screening and planning
Utilize Motivational Interviewing and Coaching skills to assist patients/families in identifying and addressing goals. Using identified strengths, encourage self-determination and independence
Act as educators for patients, families, the community, and other professionals regarding disease prevention, disease progression, impact of illness, health maintenance, and adherence to treatment regimens
Advocate for the needs and interests of patients to improve access to care and improved delivery of services
Provide ongoing assessment of patient and family needs. Monitor and alter care plan goals and interventions as necessary
Maintains timely documentation of social work services, which reflect the patient and client systems’ pertinent information for assessment and treatment; social work involvement and outcomes.
Facilitates team based care and collaboration
Work collaboratively with primary care and specialty physicians and other members of the health care team to improve quality of life
Functions as an integral member of the multidisciplinary team. Participates in case conferences and IDT meetings
Assists the health care team in understanding social/psychological factors related to patient’s care
Acts as a consultant for Agency staff regarding abuse, neglect, exploitation, and community resources
Identify HHC and community-based resources for patients and families as appropriate
In addition, the position involves other duties such as:
Participates in Agency staff meetings and appropriate interdisciplinary meetings
Conducts outreach activities for purposes of program marketing, community education, and collaboration with other service providers
Act as liaison to other community services and agencies
Participates in health care programs as required
Participates in appropriate external and internal professional activities
Participates in educational activities regarding area of expertise
Follows Agency procedures in delivering casework services
Maintains productivity standard
Will actively participate in the performance improvement process known as H3W.
Performs other duties as assigned
Master’s degree in Social Work from a school accredited by the Council on Social Work Education
2-3 years health care experience, inclusive of acute and community health experience
Licensure, Certification, Registration
Knowledge, Skills and Ability Requirements
Considerable knowledge of social, cultural, economic, political, religious, medical, psychological and legal issues which influence the behaviors of patients and families.
Familiarity with various evidence-based assessment tools: PHQ-9/PHQ-2, SLUMS, BIMS, FAST, SAD Caregiver Strain Index, etc.
Knowledge of and ability to obtain community resources (town/state/federal programs and eligibility requirements)
Proven ability to work effectively independently and in a team environment.
Must be flexible with ambiguity and change processes.
Excellent written and verbal communication skills.
Strong organization skills and attention to detail.
Strong computer skills including Microsoft Office, Epic experience a plus
New clinicians will be required to complete:
Mental Health First Aid Certification
Movement Disorder Training