Medical Social Worker

Overview IOA is on the forefront of revolutionary healthcare models, reshaping the way people can age in place. Our innovative models transform lives, enhance communities, and save healthcare systems millions of dollars. With over 23 programs, we offer multiple ways to aid seniors maintain their health, well‑being, independence, and participation in the community. Primary Responsibilities The Medical Social Worker at On Lok PACE at the Institute on Aging provides psychosocial assessment and therapeutic counseling to a caseload of clients with complex medical and psychosocial problems. The Medical Social Worker serves as the primary liaison between participants, family members, and the interdisciplinary care team. Specific Responsibilities Conduct in‑depth biopsychosocial assessments to determine participant needs across multiple domains, including physical and mental health, financial, and environmental issues. Use evidence‑informed interventions to identify participant goals, and develop and implement participant‑centered care plans that integrate with the interdisciplinary team. Join Primary Care Providers and Registered Nurses to form a core primary care team for each participant, directing the involvement of other health care disciplines on the IDT. Develop rapport and maintain care‑management relationships with participants and members of their support system as appropriate. Partner with Care Managers and other IDT members to coordinate care for participants with complex needs, monitor transitions of care, and ensure safe discharge planning. Provide supportive counseling to assist participants in coping with illness, grief, and loss. Offer crisis intervention, advocacy, problem‑solving, and appropriate therapeutic interventions. Facilitate family and care‑team meetings to ensure alignment and promote decision‑making around end‑of‑life planning, health care wishes, and goals of care. Build relationships and partnerships with community providers that support and extend social work interventions. Facilitate enrollment of On Lok PACE participants at IOA in partnership with the enrollment team. Advocate within the interdisciplinary setting and community programs related to ongoing management of mental health, co‑occurring substance abuse issues, and chronic unstable housing. Facilitate behavioral health referrals and monitor the efficacy of behavioral health interventions. Meet regularly with participants to review progress on care‑plan goals and modify as needed. Document all service delivery and encounters in the participant’s electronic health record (EHR) according to program and department standards. Educate participants and their support systems about available resources, assist in connections, and offer psychosocial education to encourage self‑management of needs. Maintain open and effective communication with the IDT and other community providers. Provide appropriate information on all significant aspects of individual participant care and program operations, while maintaining confidentiality. Continuously evaluate and promote the participants’ ability to remain safely in the community, coordinating facility placement when necessary. Participate in quality improvement studies and data collection as required. Actively participate in IDT and program meetings, activities, and problem‑solving endeavors, contributing to open lines of communication within the team. Recognize clinical or personal limitations by utilizing supervision when necessary. Understand and apply the regulatory and procedural requirements of the social work discipline within PACE, as well as policies and procedures of the Institute on Aging. Remain current in the field of professional social work by attending continuing education classes and other in‑service training to increase knowledge, skills, and attitudes related to medical social work, social work core competencies, case management, gerontology, family and community systems, and other relevant areas. Participate in and promote ongoing continuous quality improvement initiatives and Service Utilization Reviews. Actively incorporate the ethical standards of the National Association of Social Workers and uphold the core values of service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence. Perform additional reasonably related responsibilities as assigned. Requirements Must hold an MSW from an accredited school of Social Work. At least one year of professional experience working with frail elderly. At least one year of experience working in an interdisciplinary care model. Licensure is not required, but supervision toward LCSW licensure is provided. Background and Experience Experience with and understanding of the medical and psychosocial problems of functionally impaired adults and the frail elderly. Exceptional communication and presentation skills relating to the frail elderly, functionally impaired adults, their support systems, and teams of health professionals. Detail oriented with strong problem‑solving skills and the ability to prioritize multiple tasks. Computer literacy preferred. Bilingual Cantonese or Spanish preferred. Compensation Range: $85,759 – $102,495 per year. This range does not include any additional equity, benefits, or other non monetary compensation which may be included. EEO Statement Institute on Aging is an Equal Opportunity Employer. Institute on Aging is committed to cultivating a diverse and inclusive work environment and providing equal opportunities to all employees and job applicants without regard to age, race, religion, color, national origin, sex, sexual orientation, gender identity, genetic disposition, neuro‑diversity, disability, veteran status or any other protected category under federal, state and local law. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. #J-18808-Ljbffr Institute on Aging