Essential Functions:

1. Participates in the development and maintenance of treatment plans.
   • Evaluates and develops in collaboration with physician and other care team members, a Plan of Care to address/ treat psychosocial and emotional status to meet the patients’ needs.
   • Completes patient's case assessments, prepares clinical and progress notes and participates in case conference as required.
   • Involves patients and family members in developing and implementing the plan of care whenever possible.
   • Instructs other team members, patients, and families in understanding the social and emotional factors related to the health problems of the patient.
   • Instructs patients and families of correct utilization of appropriate community resources as needed.
   • Acts as a consultant to home health care interdisciplinary team members as needed.
2. Implements current medical social work practice.
   • Maintains comprehensive listings of all community services available to home care patients and their families.
   • Helps patients and families to understand, accept, and follow medical recommendations and provides services planned to maximize individual capabilities.
   • Helps patients and families with personal and environmental difficulties that predispose illness or interfere with obtaining maximum benefits from medical care.
   • Engages in resource planning by making arrangements with other supportive services for which the patient is eligible.
   • Participates in discharge planning activities and prepares appropriate documentation.
   • Implements appropriate infection control and safety measures and reports all hazards and accidents in a timely and accurate manner.
   • Maintains confidentiality of patient information.
3. Participates in professional growth and development.
   • Attends Agency in-services as required.
   • Develops and presents educational programs for Agency clinical staff as required.
   • Remains active in appropriate professional and community organizations to enhance knowledge of resources available to patients and their families.
   • Participates in Performance Improvement programs.
4. Fulfills additional performance responsibilities as assigned and as necessary.