Social Worker

Perform in-person initial assessments for enrollment of potential Eldercare participants to obtain a complete psycho-social history, to include: descriptions of cognitive status, social supports, family dynamics, mental health and substance dependency, and other current issues and needs.

Collaborate with the interdisciplinary team to develop a comprehensive care plan for each participant.

Conduct in person reassessments of enrolled participants every six months and as needed when participants’ conditions change.

Maintain regular attendance at and participate in daily Interdisciplinary Team meetings, communicate participant changes and collaborate with team members in care planning decisions and coordination for 24 hour care delivery.

Act as liaison with participant, caregivers, and community agencies regarding orientation to and ongoing relations with Interdisciplinary Team, day center, and other Eldercare staff.

Provide ongoing support, counseling, and education to participants and family regarding a variety of issues, including but not limited to: the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics and changing roles, Eldercare model and Eldercare health services.

Present requests to Interdisciplinary Team (IDT) for and coordinate admission/discharge to contracted facilities for temporary respites and permanent placement.

Act as facilitator for meetings with participant, family, caregivers, and community agencies to clarify or problem solve issues, including plan of care. Mediate discussions between all parties

Provide referrals to subsidized housing and assisted living residences. This may involve completing applications, obtaining medical records, accompanying participants to interview assessments and tours if participant has no other support systems.

Initiate referrals to external resources with community agencies such as Adult Protective Services, Housing Authority, or public utility companies. Advocate for participants with these entities for purposes of maintaining community stability.

Assist participants and caregivers to complete Advanced Directives, Medical Durable Power of Attorney (MDPOA), Proxy, and Do Not Resuscitate (DNR) directives as needed.

Assist participants with Social Security Income (SSI) and Social Security Disability Insurance (SSDI) application process as needed.

Assist participants disenrolling from Eldercare in coordinating insurance and referrals for other community or facility based services as desired by the participant.

If end of life care is appropriate, actively provide emotional support, grief counseling, education, and funeral/financial planning referral. Facilitate end of life or nursing home placement as needed.

Participate in and support Quality Improvement initiatives

Act only within the scope of his or her authority to practice.

Know and adhere to philosophy and goals of Eldercare

BLS or CPR certification required.

Masters in Social Work Degree from an accredited school of social work by the Council on Social Work Education.