Social Worker - Lakeside

Pioneer Health Care Management Inc; Sterling Heights (MI); On-site; USD 42,000 - 64,000; Full time

Job summary

Pioneer Health Care Management Inc. seeks a Social Worker - Lakeside in Sterling Heights, MI to identify residents' social, emotional and psychological needs and develop care plans.

You will educate families about post-acute options, coordinate with the interdisciplinary team, and document assessments and care conferences in the EMR.

This full-time role requires a Bachelor’s in social work or related field and at least one year of supervised health-care social work experience.

Qualifications

• Bachelor's degree in social work or related field.
• 1 year of supervised social work experience in a health care setting.

Responsibilities

• Complete and document Social Work and Psychosocial assessments for all residents within 3 days of admission or readmission.
• Ensure 3877/78 forms are completed and accurate, upon admission and annually.
• Schedule and document 72-hour Resident Care Conference for admissions and readmissions, and notify the IDT by email with date, time, resident and attendance.
• Complete MDS sections and the appropriate CAAs.
• Complete, review and update Care Plans including Psychosocial, Discharge Planning, Behavioral, Cognitive loss, mood, vision, hearing; ensure diagnoses and medications are captured.
• Monitor the behavior log book and follow up on new or changed behaviors.
• Coordinate care with the psych provider including medication management and consents.
• Coordinate all ancillary services (Dental, Ophthalmology, Audiology) with input from DON/Administrator.
• Educate residents and families related to Advanced Directives; complete Advance Directive and Code Status within 48 hours of admission.
• Arranges DME and Home Care at discharge and maintains relationships with community health resources.

Education

Bachelor's degree in social work or related human services field

Job description

Social Worker - Lakeside

Full Time Sterling Heights, MI, US

Reports to: Nursing Home Administrator

Effective Date: 7/1/2017 Review Date: 4/1/2021

Job Summary

Identifying each resident’s social, emotional and psychological needs

Developing and carrying out a plan to develop the resident’s full potential during their stay

Educates patient/family regarding post-acute options and addresses issues of choice

Assists team members with discharge planning activities

Core Responsibilities

• Complete and document Social Work and Psychosocial assessments for all residents within 3 days of their admission or readmission.
• Ensure 3877/78 forms are completed and accurate, upon admission and annually.
• Ensure all new admissions and readmissions have a scheduled 72 hour Resident Care Conference. Additionally, you will notify the IDT by email of date, time, resident and if family will be attending. This goes for quarterly and annual Resident Care Conferences as well.
• Complete MDS sections and the appropriate CAA’s.
• Completes, reviews and updates Care Plans including, Psychosocial, Discharge Planning, Behavioral, Cognitive loss, mood, vision, hearing Podiatry, dental. Ensures diagnosis, and medications are accurately captured on the resident’s care plans.
• Monitor the behavior log book and follow up on any new or changed behaviors noted.
• Monitor high risk residents including but not limited to:
• Psychiatric dx. And/or medications
• Age 55 or under
• Residents with communication barriers
• Attend the weekly Medicare Meeting
• Attend the monthly QAPI meeting and have all your data prepared to speak on. Remember to separate your lists into short and long-term residents.
• Coordinate care with the psych provider including medication management, medication consents, GDRs.
• Coordinate all ancillary services, Dental, Ophthalmology, and Audiology the resident may need or request with the input of the DON and/or Administrator.
• Educates residents & families related to Advanced Directives, completes the Advance Directive and Code Status form within 48 hours of admission.
• Greets Residents, families, etc, introduces self, and identifies purpose for visit
• Ensures daily visits and assessments x 3 days for any resident involved event including documentation.
• Documents all interactions with residents, families, Health Care Providers etc in the Medical Record.
• Demonstrates proficiency with EMR for facility.
• Handles problems of adjustment to the facility environment and maintains frequent contact with residents & families.
• As needed may be involved in in-service training of aides and staff related to resident rights and Social Services.
• Effectively and thoroughly answers patient and family questions
• If a hospice referral is indicated, coordinate care with the provider.
• Begins discharge planning for residents on admission & ongoing, working with all aspects of the interdisciplinary team to ensure an appropriate/safe resident discharge.
• Provide resident/family with written information about the resident rights related to discharge including the appeal process.
• Arranges DME & Home Care for residents at time of discharge.
• Establishes working relationships with community health, welfare and volunteer groups to promote cooperative assistance in meeting social needs of residents & families.
• Demonstrates kind, caring demeanor with resident, family and staff interactions.
• Other duties as requested

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Minimum Qualifications

• Bachelor's degree in social work – or – a Bachelor's degree in a human services field including but not limited to sociology, special education, rehabilitation counseling, gerontology and psychologyrequired
• 1 year of supervised social work experience in a health care setting working directly with individuals required