POSITION SUMMARY: 

Assists the Social Service Director with social service programs, evaluate the social needs of each resident admitted and formulate a written plan of care; review and revise plan as necessary, but not often than quarterly; refer residents and families to appropriate community resources, as necessary.

JOB QUALIFICATIONS:

Experience: One year of supervised social work experience working directly

with residents in a health-care setting.

 KEY JOB FUNCTION:

• Coordinates and sets up appointments including Dental, Podiatrist, Ophthalmologist, Psychiatrist.
• Coordinates and arranges transportation, where applicable.
• Arranges room changes, assist resident/family with adjustment to change.
• Keeps calendar for assessments, meetings and other clerical duties as needed, and schedules meetings for residents, staff, families.
• Assist in facilitating family group meetings and attends IDT meetings.
• Arranges for DME and home services at time of discharge and follows up on residents’ possessions after discharge.

COMMUNICATION REQUIREMENTS OF ESSENTIAL JOB FUNCTIONS:

• Decide for obtaining needed adaptive equipment, clothing and

personal items.

• With resident’s permission, maintain contact with family to report on changes. In health, current goals, resident’s rights, discharge planning, and to encourage participation in care planning.
• Make referrals and obtain services from outside entities, such as talking books, absentee ballots, and community wheelchair transportation.
• Assist residents with financial and legal matters, such as applying for pension,

referrals to lawyers, and referrals to funeral homes for pre-planning arrangements.

• Assist with discharge-planning services, such as helping to place a resident on a

waiting list for community congregate living, arranging intake for home-care services for residents returning home, assisting with transfer arrangements to other facilities. Complete discharge plan in accordance with discharge-plan policy.

• Develop relationship with resident and family and provide or arrange for

provision of needed counseling services.

• As a member of the interdisciplinary team, identify and seek ways to support.

resident’s individual needs, preferences, customary routines, concerns, and choices through the assessment and care-planning process.

• Build relationships between residents and staff and teach staff to understand and

support residents’ individual needs.

• Promote actions by staff that maintain or enhance each resident’s dignity in

full recognition of each resident’s individuality.

• Assist residents in the decision-making process concerning their own health care,

and whether they would like anyone else to be involved in those decisions.

• Assist staff to inform residents, and those they designate, about the residents.

health status and health-care choices and their ramifications.

• Provide alternatives to drug therapy and/or restraints by understanding and

communicating to staff why residents act as they do, what they are attempting to communicate, and what needs the staff must meet.

• Counsel in dealing with feelings about grief, depression, disability, death, dying,

or other emotional, mental, environmental, or physical limitations.

• Find options, which best meet, the physical and emotional needs of the residents.

• Work with families and residents on social interaction, reality orientation, and intellectual stimulation.
• Work with families and community resources, as needed, to solve financial needs. and promote emotional security regarding financial stability.
• Document interaction with residents and/or families in the assessment and care

plans as required by the state standards.

• Complete the social service portion of the Minimum Data Set within 14 days of

admission.

• Document the social-care component of the Comprehensive Care Plan for each

resident as identified by the health-care committee within 7 days of completion of the MDS. Subsequent progress notes and care plan up dating should be documented every 9 days or as resident’s condition changes.

• Identify community services and help the residents’ families utilize them when.

needed.

• Compile and record social histories to assist in understanding residents.

backgrounds, family problems, resources, histories of illnesses, interests, etc.

Record pertinent social data about medically related personal and family problems.

in residents’ medical records.

• Assist residents in utilizing individual and group activities to their best advantage.
• Observe, record, and notify staff of changes in attitude, behavior, or personality,

especially depression, anxiety, withdrawal, and uncontrollable aggression.