Social Worker MSW - HomeCare

Location Detail: 680 Main Street Watertown (10326)

Shift Detail: Combination of Mon thru Friday to cover greater Waterbury Area. Weekends not required.

The Home Care Social Worker (MSW/LMSW) is a Master’s prepared, Licensed/License eligible Clinician who will engage patients, in their home, to determine their short and long-term needs, and will provide short term interventions to meet patient’s goals of care. The Home Care Social Worker will collaborate with patients, their families, physicians, and home care team to identify and address patient’s bio-psychosocial needs, barriers to care, risk-factors, etc. The Home Care Social Worker is familiar working with patients who have complex health care and psychosocial problems. The Home Care Social Worker works

independently and uses critical thinking skills to make accurate, and at times, quick judgments, and has the ability to respond appropriately to crisis situations.

Completes comprehensive in-home psychosocial evaluations. Evaluations include:

• Consideration of developmental, social and/or cultural, substance abuse, psychological, environmental, and medical issues
• Physical, social, emotional, and familial characteristics
• Use of evidence-based assessment tools to determine cognitive status and behavioral health needs including Dementia, Depression, Anxiety, etc.
• Home safety, family dynamics, caregiver strain, and other risk factors including suicide, and access to basic needs.
• Patient/family understanding of their disease treatment options
• Strengths, available supports, and barriers to care
• Determine appropriate level of care including needs for long/short-term skilled-nursing facilities, assisted living facilities, adult day care, etc.
• Collaborates with the interdisciplinary team regarding patients that were identified for Social Work Services, and through IDT/case communication, assists with identifying patients that would benefit from Social Work Services.
• Based on a comprehensive, culturally competent assessment collaborates with the patient and family to create a care plan with measurable goals. Implements short-term interventions to address identified barriers and promote health and well-being.
• Provides clinical treatment services in form of triage, crisis intervention, individual or family therapy, screening and planning
• Utilize Motivational Interviewing and Coaching skills to assist patients/families in identifying and addressing goals. Using identified strengths, encourage self-determination and independence
• In collaboration with the multi-disciplinary team, act as an educator for patients, families, the community, and other professionals regarding disease prevention, disease progression, impact of illness, health maintenance, adherence to treatment regimens, and accessing short and long-term community resources
• Advocate for the needs and interests of patients to improve access to care and improved delivery of services. Provide patients and families resources in preparation for patient discharges.
• Maintains timely documentation of social work services, which reflect the patient and client systems’ pertinent information for assessment and treatment; social work involvement and outcomes.
• Facilitates team based care and collaboration
• Work collaboratively with primary care and specialty physicians, other members of the health care team to improve quality of life, and meeting patient’s goals of care
• Functions as an integral member of the multidisciplinary team. Participates in case conferences and IDT meetings
• Assists the health care team in understanding social/psychological factors related to patient’s care
• Acts as a consultant for Agency staff regarding abuse, neglect, exploitation, and community resources
• Identify HHC and community-based resources for patients and families as appropriate
• Performs other duties as assigned

Qualifications

Master’s Degree in Social Work

1 – 2 years clinical experience

Experience in a healthcare setting strongly preferred

Licensure required within 1 year of hire