Home Health Medical Social Worker

Provides coordinated care in the home to patients/clients of all age groups and perform psychosocial assessments, analysis, counseling and referrals to meet the needs of the patient/client and family. Participates in the coordination of care.

• Performs ongoing clinical assessment of home health patients/clients to identify psychosocial, financial, environmental and community resource needs as evidenced by the POC, documentation, clinical records, case conferences and community resource referrals.

• Develops and evaluates the plan of care in partnership with the patient/client, representative (if any), and caregiver(s).

• Accepts clinical assignments that are consistent with education and competence to meet the needs of the patients/clients.

• Provides services that are ordered by the physician as indicated in the plan of care, including patient/client, caregiver and family counseling and patient/client and caregiver education. Prepares clinical notes.

• Uses effective interpersonal relations and communication skills; facilitates the use of these skills by other team members to achieve desirable outcomes.

• Communicates with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care.

• Meets mandatory continuing education requirements of the Agency and licensing board.

• Demonstrates commitment, professional growth and competency by maintaining a working knowledge of public and private eligibility standards and requirements.

• Promotes the Agency philosophy and administrative policies to ensure quality of care.

• Collaborates with the interdisciplinary team to promote coordination of patient/client care.

• Participates in the Agency's QAPI program.

• Participates in Agency-sponsored in-service training.