Social Worker (LMSW/LLMSW) - Several Positions Open

LifeCircles PACE provides all-inclusive care to frail seniors in the community who desire to remain in their home but need additional support to achieve that goal. Geriatric appropriate clinical services are provided both in the onsite clinics and in participant’s homes. 

Overview

The Master’s Social Worker coordinates care for participants in conjunction with the Interdisciplinary Team, ensuring that participant’s emotional and psychosocial needs are met.  The MSW continually assesses, communicates, and advocates participant’s needs.  

What you’ll do

Participates in the Interdisciplinary Team’s initial assessments, care planning, and periodic re-assessments (minimally every 6 months) of participant’s case

Communicates participant changes to team members, deeply engages in IDT meetings and discussions, and the development of the participant plan of care.

Develops a person centered and comprehensive care plan.

Coordinates 24-hour care delivery. 

Provides individual family counseling and develops and leads group counseling and activities.

Coordinates discharge planning and admissions to long-term care facilities.

Facilitates conversations and completes documents for Advance Care Planning, health care wishes and identifying a health care proxy. 

Maintains records, including progress notes, care plans and periodic reassessments.

Links participants with entitlements through public agencies.

Refers participants to, and collaborates with, appropriate community agencies and resources, and acts as a liaison and advocate.

Consults with and advises team members as to the relationship of social, emotional, and cultural factors to health and medical care, and as to the availability of social services in the community.

Participates in Quality Improvement Activities.

Documents in the participant’s medical record as required by policy