PACE KC Social Worker

The Social Worker contributes the psychosocial perspective to the interdisciplinary evaluation, assessment, plan of care, ongoing services and disenrollment process that occur once prospective participants begin the intake process and continue with enrollment and ongoing services. Routinely assesses the needs of participants and families and determines the most appropriate and effective social services interventions to meet participant goals. Based on the assessment and/or evaluation of the participant, the Social Worker works in coordination with the IDT, Behavioral Health Specialist, contracted providers, and others to implement the plan of care and to provide psych/social interventions. The Social Worker acts as an education resource for the PACE team and supports the organizations goal to provide high-quality, person-centered care to all participants.

Primary Responsibilities

• Acts as and engaged member of the Interdisciplinary Team (IDT). Regularly attends meetings and provides meaningful input.
• Performs in-person initial assessments for enrolling participants to obtain a complete psychosocial history, which may include descriptions of cognitive status, social supports, family dynamics mental health and substance dependency and other issues and needs. Coordinates with the IDT to develop a comprehensive plan of care for each participant.
• Reassesses participants on a semi-annual and as-needed basis and coordinates with the IDT to update the plan of care for each participant.
• Responsible for the psychosocial well being of participants in coordination with the IDT. Provides ongoing support 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, PACE model and PACE health services.
• Identifies, provides and/or coordinates for the medically-related social, psychological and spiritual needs of the participants. Implements social work interventions, case management, or psychosocial support.
• Support the IDT with acute and complex case management.
• Acts as facilitator for meetings with participant, family, caregivers, and community agencies to clarify, or problem solves issues regarding the plan of care. Mediates discussions between all parties.
• If hospice care is appropriate actively provides emotional support, grief work, education and funeral/financial planning referral. Facilitates hospice or nursing home placement as needed. Initiate referrals to external resources with community agencies such as Adult Protective Services, Housing Resuscitate (DNR) directives as needed.
• Acts as an educational resource to other team members, participants, families, and others regarding topics such as dementia, difficult behaviors, self-determination, validation, and person-centered care.
• Engages in coordination with outside agencies such as Adult Protective Services, Ombudsman, contracted providers and facilities, etc. in coordination of care and/or on behalf of the participant.
• Identifies opportunities for quality improvement and engages organizational mechanisms as needed.
• In coordination with the Center Director and other members of the Social Work Department, may design, implement, and/or facilitate participant and/or family support groups
• Performs other duties as assigned.

Education/Qualifications

• Masters degree Social Work.
• Licensed Master Social Worker (LMSW) preferred.
• Minimum of 2 year experience working with the elderly population as a MSW.
• Knowledge with the psychosocial issues of the chronically ill and their caregivers.
• Knowledge of providing group and individualized recreational therapy to maintain participant maximum independence and function.
• Maintain accurate records and to prepare clear and concise reports, correspondence, and other written.
• Current driver's license, auto insurance, and dependable transportation.

Skills

• Effective oral and written communication.
• Strong interpersonal skills with ability to build.
• Effective organizational skills with attention to detail and time management skills.
• Strong analytical and problem-solving.
• Proficient with Microsoft Office Suite or related.

About Swope Health Services:

For 56 years, the mission of Swope Health mission has been to improve the health and wellness of the community by delivering accessible, quality, comprehensive patient care to all. Founded in 1969 by E. Frank Ellis, Swope Health opened as “Model Cities Health Corporation” in the basement of Metropolitan Missionary Baptist Church with 20 associates and a $100,000 budget to serve 2,000 patients a year. Since then, Swope has since expanded its size, scope, and service offerings to include behavioral and dental care, services for the unhoused, mobile services and school-based clinics, and the PACE KC Adult Wellness Center.

Swope Health serves as a community health asset in the region – transforming lives, strengthening community, and powering our prosperity. Swope Health is committed to maintaining its focus on patient care and experience as well as an integrated, holistic model of health care, ensuring that everyone in the community can be served. The organization’s high-quality services, strong financials, and visionary leadership team position them well to sustain and deepen their impact into the future.

Swope Health Services supports its team members with:
1. Medical benefits (including a Health Savings Account option), dental and vision
2. 401(k) retirement plan with company match
3. Company-paid benefits such as life insurance, Accidental Death & Dismemberment, and Short and Long Term Disability
4. Flexible Spending Account
5. Paid Days Off beginning at 15 days annually
6. Nine annual company-paid holidays; One annual paid personal day

*Swope Health is an affirmative-action, equal-opportunity employer. We consider all qualified applicants without regard to race, color, creed, religion, gender, national origin, age, marital status, veteran status, or disability.

Equal Opportunity Employer

This employer is required to notify all applicants of their rights pursuant to federal employment laws.
For further information, please review the Know Your Rights notice from the Department of Labor.

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