To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
Completes assessment up to level of competency on every home visit and performs prescribed interventions in accordance with a plan of care. Assesses patient's level of competency, including all factors relevant to
patient/family safety and medical needs. Assesses psychological, social and environmental needs, and abilities of
patients as related to medical diagnosis/situations. Assessed financial condition and refers to appropriate financial entitlements based on findings. Demonstrates knowledge of medical/geriatric population.
25% Case Management:
Initiates contact with patient/caregiver within 24 hours of receipt of referral from
skilled discipline. Completes psychosocial assessment within 72 hours of initial visit with
patient/caregiver. Develops Treatment Plan with identification of goals and interventions relating
to patient's illness/needs. Participates in interdisciplinary patient care conferences according to agency
policy. Communicates findings as needed to patient's physician. Provides consultation to agency staff regarding social and emotional needs of patient's and caregivers.
Completes initial MSW evaluation including patient's social and emotional needs
as related to illness.
Documents social work interventions and goals on approved forms.
Records all phone conversations made on behalf of patient in the clinical record.
Documents any changes in patient care and condition.
Documents patient care conferences
Completes Discharge/Transfer Summary on each patient as indicated.
Communicates need for appropriate consultation when responsibilities exceed
level of knowledge and experience.Communicates promptly to the RN case manager or Director of Clinical
Services, pertinent patient problems/changes. Communicates clearly with patient, family, caregiver network. Calls prior tohome visits to establish and/or verify the visit schedule.Communicates in a professional manner with agency staff and outside resources.
10% Policy and Procedure:
Supports and adheres to agency policies and procedures.
Responsible for following guidelines of Medicare, Medicaid and other insurance
carriers and providers. Adheres to safety policies and procedures.
Participates in performance improvement activities. Respects confidentiality in all aspects of position; follows HIPAA requirements. Participates in staff meetings, in-service programs and other required meetings.
Reviews and updates availability of community resources on a regular basis. Provides timely submission of annual requirements
Must have LCSW certification
Graduate of Master's Degree program in social work accredited by the
Council on Social Work Education, who has a minimum of three (3) years’ experience in
Physical Requirements: Ability to perform essential job functions varying in strength
and agility from office work requiring good eyesight and hearing to physical activity
involving periods of sitting, standing and occasional movement of patients.
Reports to: Director of Clinical Services