Employment Type:

Shift:

Description:

LIFE at St Francis Healthcare, a member of Trinity Health PACE, is seeking a full-time Social Worker for its location in Wilmington, Delaware.

The primary purpose of this position is to plan, organize, and implement social services to PACE Organization (PO) participants and families. Responsible for but not limited to assessment, treatment, teaching and counseling participants, caregiver or other appropriate representatives. Social Worker interventions may include individual participant contacts, appropriate collateral contact, participant and family education, assessment and counseling, provision of resources, addressing mental health needed, ongoing case management, advocacy to ensure participant and caregiver needs are met and addressed and disenrollment procedures.

Programs of All-Inclusive Care for the Elderly (PACE) coordinate and provide all needed preventive, primary, acute and long-term care services so that older individuals can continue living in the community. PACE is an innovative model that enables individuals who are 55 years old or older and certified by their state to need nursing home care to live as independently as possible. Through PACE, today’s fragmented health care financing and delivery system comes together to serve the unique needs of each individual in a way that makes sense to the frail elderly, their informal caregivers, health care providers and policy makers.

LIFE at St Francis Healthcare provides a competitive compensation and benefit package that complements this opportunity for personal growth and professional advancement.

Benefits of joining a winning team!

• Warm and supportive environment

• Enjoy a truly patient-centered focus

• Excel with supportive, motivated colleagues in an inspiring environment

• Flexibility

• Competitive salary

• Career paths and professional development

• Learn the industry's best, easy-to-use, advanced technology

• Other benefits

• Health, dental and vision insurance

• Short and long-term disability

• 403b

• Generous paid time off

• Mileage reimbursement

• Comprehensive orientation

Essential Functions include but are not limited to:

• Reflects the skills knowledge and abilities serving in the role of a leader. Define and share a strategy and vision; align resources toward achievement of organization results; grow and sustain the organization; identify, lead, and embrace change.

• Participate as a member of the interdisciplinary team (IDT). Communicate participant changes, and collaborates on care planning decisions and coordination for 24-hour care delivery.

• Perform initial, semi-annual, unscheduled, and annual assessments of participants. Coordinates with IDT to develop comprehensive plan of care for each participant.

• Involved in the development and implementation of QAPI activities.

• Conduct initial intake meeting with family members and others, while coordinating ongoing family meetings as needed.

• Provide individual and family counseling as needed or prescribed in the plan of care; develop and lead group counseling and support activities.

• Provide ongoing support, counsel, and education to participants and family regarding a variety of issues, including but not limited to: the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics and changing roles, PACE model and PACE health services.

• Maintain current, written case management records, including ongoing documentation of services provided, reassessment of changing needs and participant's expressed wishes.

• Perform home visits periodically or as needed to asses living environment and support system.

• Assist with ongoing financial eligibility for participants, including recertification as needed.

• Provide training, supervision, oversight and evaluation to Case Managers and case management to participants and families.

• Act as liaison between the participant and other agencies such as Department of Aging, Social Security Administration, Medicaid, etc.

• Assist participants and caregivers in filing grievances and appeals.

• Act as a resource to other team members, and day center staff regarding topics such as dementia, difficult behaviors, and difficult personalities.

• Assure that any personal care needs are communicated to the family with special attention to clothing and DME needs while participants are in hospital or short-term rehab stays and communicate relevant information to the interdisciplinary team about participants while they are admitted.

• In conjunction with the interdisciplinary team, coordinate discharge planning for participants returning home from hospital or

• nursing facility.

• Provides crisis intervention and advocacy as required.

• Actively provide emotional support, grief work, education, funeral and/or financial planning referrals when hospice care is appropriate. Facilitate hospice or nursing home placement as needed. Initiate referrals to external resources with community agencies such as Adult Protective.

• Assist participants and caregivers to complete Medical Durable Power Of Attorney (MDPOA) Proxy, and Do Not Resuscitate (DNR) directives as needed.

• Coordinate transitional care to ensure continuation of care by assisting participants with reinstatement of conventional Medicare and Medicaid benefits, transition care to other providers, make referrals and ensure participant medical records are available to new providers in the event of participant termination of the PACE Program.

Requirements:

• Must possess a comprehensive knowledge of social work as normally obtained through a Master's degree in social work and two (2)years of experience, including one (1) year working with the frail or elderly population or if less than one (1) year of experience, must receive appropriate training from the PACE organization on working with a frail or elderly population upon hiring.

• Current license in social work within the state of PACE Organization preferred. A combination of education and experience may be acceptable.

• Experience working on a multidisciplinary team in a hospital, nursing home or community-based setting is preferred.

• Experience and thorough knowledge of social service principles and practices.

• Knowledge of financing mechanisms such as Medicare, Medicaid and other payment systems.

• Valid driver's license and ability to provide a reliable means of transportation required.

• Must be action-oriented, have business acumen, manage conflict well, be customer focused, have high decision quality, flexibility to adapt to ongoing change and have organizational agility. Ability to work with minimal supervision and exercise independent judgment.

• Possess interpersonal skills to drive collaboration, commitment and productivity when working with cross-functional teams, customers and end users. Must be comfortable functioning in a virtual, collaborative shared leadership environment.

• Demonstrates superior written, verbal and/or American Sign Language (ASL) communication and presentation skills appropriate for audience comprehension. Well-developed communication skills, written, oral or through ASL, that may be used either in an on-site or virtual environment is required. Able to communicate effectively with individuals and groups representing diverse perspectives.

• Comprehensive to expert proficiency with Microsoft product suite (MS Word, Excel, Power Point, etc.); basic knowledge and experience with electronic mail and calendaring system. Knowledge of social service delivery systems necessary, experience preferred. Ability to type with speed and accuracy. Ability to use other software as required to perform the essential functions of the job.

• Possesses a high degree of personal accountability, responsibility and independent decision-making abilities with the skills to plan, organize, develop, implement and interpret programs, goals, objectives, policies and procedures of the organization in line with mission, vision, and philosophy of TH PACE.

• Excellent organizational skills. Ability to perform multiple duties and functions related to daily operations and maintain excellent customer service skills. Ability to perform frequent detailed tasks and provide immediate service with frequent interruptions. Ability to change and be flexible with work priorities. Strong problem-solving skills.

• Ability to research, analyze and assimilate information from various on-site or virtual sources based on technical and experience-based knowledge. Must exhibit critical thinking skills and possess the ability to prioritize workload.

• Position may require up to 10%travel within the Centers geographic region.

We have an energizing new vision and strategy. Join us and shape the future of healthcare!

Apply now!

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.