Social Worker, LMSW - PACE (Full-Time)

Proposed Schedule: 40 hours per week. Monday-Friday 8am-4:30pm.

Summary

The Program of All-Inclusive Care for the Elderly (PACE) is a community-based program that provides coordinated medical and social services to eligible older adults who want to continue living in their own home despite chronic care needs. The PACE Social Worker (LMSW) is a member of the PACE Interdisciplinary Team (IDT) and responsible for completing comprehensive initial social work assessments for new PACE participants and social work reassessments for existing PACE participants as part of the PACE IDT care planning process.

The PACE Social Worker (LMSW) provides direct social work and care management services to PACE participants in concert with the PACE IDT and current care plan. These services include participant social work screenings, case management and counseling coordination, and referrals to community agencies as appropriate.

The PACE Social Worker (LMSW) is responsible for being knowledgeable regarding local community resources and services available to participants and caregivers.

The PACE Social Worker (LMSW) educates participants, caregivers, and PACE staff on psychosocial factors and participant/caregiver dynamics impacting participant care.

Essential Duties and Responsibilities:

• Participates as a PACE Interdisciplinary Team (IDT) member and is responsible for completing a comprehensive initial social work assessment and other assessments as identified for new PACE participants and social work reassessments on existing PACE participants as part of the PACE IDT care planning process.

• In collaboration with the IDT, develops care plans for social work and delivers social work interventions to participants identifying and considering the medical, physical, social, and emotional needs of PACE participants.

• Maintains responsibility for the psychosocial well-being of participants through the coordination of 24-hour care delivery working in concert with the IDT. Identifies, provides, and coordinates participants' medically related social, psychological, and spiritual needs. Implements and/or coordinates social work interventions, case management, individual and caregiver counseling, and comprehensive psychosocial support.

• Consults with and advises PACE staff members on the relationship of social, emotional, and cultural factors impacting access to health, medical care, and community resources.

• In concert with the IDT, refers participants and families to appropriate community resources, acts as a liaison with such organizations, and serves as a care advocate for PACE participants at all times.

• Monitors PACE participants for changes in their health and psychosocial status that require a social work reassessment. Promptly communicates pertinent changes in participant status to the IDT.

• Provides ongoing support and education to participants and caregivers regarding the aging process, dementia management, grief and loss, end-of-life considerations, disease processes, family dynamics, and the PACE service delivery model.

• Completes and maintains social work documentation in the PACE EHR in accordance with the federal PACE regulation and organizational policy.

• Attends IDT and morning meetings and reports on participants’ social status.

• Maintains knowledge of Medicaid financial eligibility criteria, including documentation to be completed.

• Maintains knowledge of participant liability and applicable share of cost.

• Maintains knowledge of applicable state nursing home Level of Care requirements.

• Supports the PACE Quality Improvement program and participates in PACE Quality Improvement activities as assigned.

• Other duties as assigned.