Job Description

Home Health Social Worker--Per Diem

When you join the growing BILH team, you're not just taking a job, you're making a difference in people's lives.

The Home Health Social Worker provides a wide range of services to patients and families while consistently exercising judgment and discretion to determine the patient and family's unique spiritual/cultural beliefs, strengths, coping skills, etc. Assessment is ongoing and the Plan of Care reflects the Medical Social Worker's analysis of and conclusions regarding unique bio-psychosocial needs of the patient/family.

Direct Patient Care

• Coordinates social work services for patients and their families
• Manages IDT patient plan of care for social work interventions
• Provides person and family centered, comprehensive psychosocial assessment
• Provides psychosocial interventions with the highest integrity related to cultural appropriateness and developmental stage along the continuum of illness including:
  • supportive counseling
  • psychoeducation
  • anticipatory guidance
  • advocacy
  • facilitation of family meetings
  • linkage to community resources
  • non-pharmacological pain and symptom management
• Reinforces patient and family personhood and coping as they negotiate the complexities of illness
• Provides clinical guidance and consultation to interdisciplinary teams
• Provides safe and comprehensive care coordination and discharge planning as indicated. Assesses team coping with challenging clinical cases. Provides guidance and debriefing as necessary.
• Makes scheduled and unscheduled visits as a member of the Interdisciplinary Team to provide psychosocial assessment of patient/family functioning. Schedules and prioritizes visits based on the acuity level of the patient/family. Makes informational visits as requested by manager to prospective patients/families.
• Provides written psychosocial assessment of patient and family and communicates the following in a timely manner: psychosocial strengths and weaknesses, including coping skills, grief reactions, support systems, high risk factors for complicated bereavement and the need for community resources.
• Provides individual and/or family counseling and reassesses psychosocial factors during every visit to assure optimal outcomes. Initiates and/or participates in patient care conferences or family meetings as needed or requested and completes appropriate documentation in the electronic record.
• Upon assessing patient/family needs, the Social Worker makes all appropriate referrals to other community agencies in a timely manner; these include, but are not limited to accessing and applications for financial resources, nursing home placements, etc.
• As a Mandated Reporter, demonstrates knowledge of family violence, child/elder/disabled neglect and abuse so as to identify those at risk and refer them to appropriate agencies under the guidance of the Manager/Director. Demonstrates knowledge of crisis intervention theory.
• Facilitates or cofacilitates monthly support groups for IDT, and assists with the provision of a Bereavement Group support, as needed.
• Participates in weekly IDT meetings to provide ongoing updates, planning and revision of the POC as appropriate to patient/family changing needs and documented in biweekly updates. Participates in orientation, education, in-service training and QAPI [Quality Assurance Performance Improvement] program of Home Health.
• Provides consultation to other health professional personnel regarding psychosocial issues and provides in-service education as requested.

Documentation

• Clinical visit notes support the need for medical social services in light of the patient's overall medical condition and experiences; the complexity of the services performed and the plan for the next visit based on the rationale of prior results.
• Initial assessment must be completed within 5 days of admission
• Completes documentation in accordance with agency timeliness policies.
• IDT notes completed timely including risk assessment and follow up plan

Qualifications

• Master's degree in Social Work (MSW) from an accredited school of social work.
• Holds a current LCSW, and is licensed to work in Massachusetts.
• Current Massachusetts Licensed Independent Clinical Social Worker (LICSW) preferred.
• Maintains an American Heart Association (AHA) CPR certification
• Minimum of 3 years of Medical Social Work experience.
• At least 1-year experience in Home Health care.

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled

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