Role: Social Worker (MSW)

Organization: Edenbridge PACE at West Baltimore 

Location: West Baltimore

Start Date: March 2024

Status: Full-time

Mission: To allow frail elderly people to age in the location of their choosing and continue to lead connected, meaningful lives

The Social Worker role offers a unique opportunity to help build a new PACE (Program of All-Inclusive Care for the Elderly) program in West Baltimore within the framework of a supportive, innovative, and expert leadership team and company. Together with our coalition of strong partners within the community, the Social Worker will work closely with the Executive Director and Program Director to carry out our PACE model of care, and have a transformative impact on a particularly under-served community.

Seven core principles drive our approach to care. These include:

1. Create and Sustain Meaningful Lives: Our model aims to help elders create and sustain meaningful lives — from social relationships, spirituality, cultural life, work, or service. We support elders with cognitive and physical disability to sustain meaning in their daily lives. We form close community partnerships to help elders engage outside our centers.
2. Respect the Right to Independence: Edenbridge aims always to follow our participants’ wishes. Wherever possible, participants maintain control over all decisions — from medical procedures to what to eat for dinner.
3. Pay Attention to What Is Working Well: Our goal is to multiply the days each participant is glad to be alive. We encourage participants’ positive experiences of daily life, supporting the things that matter most to them.
4. Provide the Right Amount of Medical Care:  Elders often have many diagnoses, medications and specialists, involving complex care decisions. We help our participants understand their choices. We deliver thoughtful, appropriate and personalized care, doing what our participants want — nothing more and nothing less.
5. Guide All the Care Provided: We always follow and guide our participants’ care — in their homes, at our center, in the hospital, and everywhere.
6. Live with Our Communities, Not Just in Them: We work in communities where aging in place is valued and integrated care is a shared mission. We build deep relationships with community organizations (see video) beginning long before we open our doors. We aim to reach beyond the walls of the center to bring community members in and participants out for person-to-person connection.
7. Employ Technology Thoughtfully, Not Aggressively: We use technology because it can enrich the lives of participants, improving care and connecting family members with their loved ones and their care providers. But we use technology only to complement — never replace — direct human interaction.

To help us achieve this mission, we are looking for an experienced Home Care Coordinator who will provide nursing care to our PACE participants and oversight to our home healthcare team. This position will report to the Clinic Manager RN.

Main Responsibilities:

• Collaborates with members of the participant care team to facilitate the coordination of appropriate, cost-effective services that are consistent with each participant's plan of care, and help achieve an optimal level of independence, and enhance quality of life
• Provides psychosocial/behavioral health evaluations of participants
• Assists in developing and implementing participant care plans
• Communicates observations and recommends interventions for participant care
• Problem identification, psychosocial assessment, financial counseling/referral, accessing community resources, guiding the participant through health-related processes, or consultation and support to other health care professionals
• Meets all required regulatory requirements including adherence to PACE policies and procedures and documentation
• Participates as a member of the IDT to include care planning, family meetings, providing directcare, facilitating meetings, problem solving, and documentation
• Develops workflow, processes, and programming, departmental specific, to ensure efficiency inmeeting participant needs
• Engages with LEAN training and Principals and utilizes training to improve organizational effectiveness
• Participates in meetings with community partners and contracted providers
• Provides Social Work coverage as needed both internally and externally (rounding to facilities as needed)

Qualifications:

Edenbridge Health is committed to building a diverse and inclusive organization. For our Social Workerrole, we are looking for the following qualifications:

• Master’s degree in Social Work
• Current licensure to practice in Maryland
• One year(s) of health care experience in a hospital, long-term or home health care setting
• One year(s) of experience with a frail or elderly population preferred
• Must submit to and pass a pre-employment criminal background check
• Up-to-date vaccinations, including COVID vaccine, required
• Must have a current Driver’s License and driving record must be in compliance with Company policy. Must maintain current automobile insurance.

Learn more at:

edenbridgehealth.org

Interested candidates, please apply by submitting your resume athttps://edenbridgehealth.applytojob.com/