Within an Interdisciplinary Care Team setting, Social Worker/Counselor promotes and maintains the mental and social health of enrolled participants through assessment, treatment, teaching and counseling.  Provides basic casework and consultation for Northland PACE participants.  Facilitates communication between participants, their family and the Care Team.  Responsible for the implementation of social work care plan and coordination of social work with other services.

Primary Responsibilities: The Social Worker/Counselor’s duties shall include, but not be limited to:

• Completes assessments at admission and for semi-annual care planning according to regulatory requirements and as condition change indicates.
• Determines participant and family needs related to social support, financial support, counseling and housing.
• Confers with participant and family to identify participant goals and expectations.
• Coordinates with the interdisciplinary team to develop a comprehensive care plan for each participant.
• Provides individual and group counseling to participants and their families as needed or prescribed in the care plan.
• Coordinates the completion of participant’s health care wishes and advance directives in cooperation with their primary care physician, the participant and their family.
• Provides discharge planning in the event of disenrollment.
• Facilitates communication between participant, family and Care Team to maximize or maintain participant support systems.
• Facilitates or participates in family meetings as required.
• May assist in facilitating the Participant Council to create a vehicle for dialogue between participants and the Care Team and empower participant responsibility.
• Conducts family support groups, education or training sessions and routine Family Caregiver meetings for education, support and dialogue.
• Ensures that the IDT is informed of care plan changes and requirements and logistics are appropriately arranged to include transportation, escorts, meals and appointments.
• Works with Site Manager to provide orientation and in-service programs for Care Team to enhance understanding of psychosocial issues and meet regulatory requirements and support performance improvement.
• Coordinates with mental health-related providers including drug and alcohol treatment to arrange appointments and share pertinent information.
• Completes and ensures completion of documentation of clinical services reviewing medical record to continuity and completeness.
• Participates in quality studies according to the quality plan.
• Recommends studies for the annual quality plan.
• Participates in committees that support performance improvement.
• Provides discharge planning in the event of disenrollment; completing disenrollment paperwork, communicating with SAA and IDT as well as other relevant community agencies.
• Provides information to Skilled Nursing Facilities, Memory Care/Basic Care Facilities and Adult Family Foster Care Homes when looking for placement for participants.
• Petitions for guardianships when deemed appropriate by the interdisciplinary team.
• Understands and follows Northland PACE Program policies, procedures and protocols.

Education/Experience:  Master’s Degree, Bachelor’s Degree from a school of Social Work accredited by the Council on Social Work Education or Licensed Professional Counselor or Licensed Professional Clinical Counselor.

Licensure, registry or certification required:  Must maintain current licensure/certification within scope of practice.

Special Training:  Must be able to work effectively in a team environment.  Must be able to communicate effectively.  Must possess strong interpersonal and organizational skills.  Ability to adapt to change in a positive/professional manner. Must possess problem-solving skills.  Must meet standardized competencies for standards of medical care and established for position.  Must be medically cleared for communicable diseases.  Must have all immunizations up to date before engaging in direct participant contact.

Physical Demands:  Must be able to see, hear, and verbally communicate.  Must be able to move about freely and possess manual dexterity and visual acuity. 

Working Conditions:  Primarily inside, well-lit, climate controlled environment.  Potential exposure to infectious disease and environmental hazards. Frequent home and hospital visits.