Medical Social Worker

Job Description

About the Company

The Institute on Aging (IOA) is at the forefront of revolutionizing healthcare models, aiming to reshape how people can age in place. They focus on innovative approaches to transform lives, enhance communities, and achieve significant healthcare system savings. Rather than adhering to outdated designs, IOA consistently challenges the “status-quo” to create new and more innovative ways to help aging adults and adults with disabilities maintain their quality of life. With over 23 distinct programs, IOA offers multiple avenues to support seniors in maintaining their health, well-being, independence, and community participation, thereby fulfilling its core mission. IOA is committed to cultivating a diverse and inclusive work environment, providing equal opportunities to all employees and job applicants regardless of various protected characteristics.

Job Description: Medical Social Worker

Primary Responsibility:
The Medical Social Worker at On Lok PACE (Program of All-Inclusive Care for the Elderly) at the Institute on Aging (IOA) is responsible for providing psychosocial assessment and therapeutic counseling to a caseload of clients who present with complex medical and psychosocial problems. This role serves as the primary liaison between participants, their family members, and the interdisciplinary care team (IDT).

Specific Responsibilities:

• Conducts in-depth biopsychosocial assessments to identify participant needs across various domains, including physical and mental health, financial, and environmental issues.
• Utilizes evidence-informed interventions to elicit participant goals and develops and initiates a participant-centered care plan that integrates seamlessly with the IDT.
• Forms a core primary care team with Primary Care Providers and Registered Nurses for each participant, directing the involvement of other healthcare disciplines on the IDT.
• Develops and maintains a rapport and care management relationship with participants and their support systems as appropriate.
• Partners with the assigned Care Manager and other IDT members to coordinate care for participants with complex needs requiring multiple services, monitoring transitions of care and ensuring safe discharge planning.
• Provides supportive counseling to assist participants in coping with illness, grief, and loss, including crisis intervention, advocacy, problem-solving, and appropriate therapeutic interventions.
• Facilitates family and care team meetings to ensure alignment and promote decision-making regarding end-of-life planning, healthcare wishes, and goals of care.
• Cultivates relationships and partnerships with community providers to support and extend social work interventions.
• Facilitates the enrollment of On Lok PACE participants at IOA in partnership with the On Lok PACE enrollment team.
• Fulfills an advocacy role within the interdisciplinary setting and community programs, particularly for ongoing management of mental health, co-occurring substance abuse issues, and chronic issues of unstable housing.
• Facilitates behavioral health referrals and helps monitor the efficacy of behavioral health interventions.
• Meets regularly with participants consistent with program guidelines to review progress on care plan goals and modify as needed.
• Documents all service delivery and encounters in the participant’s electronic health record (EHR) according to program and department standards.
• Educates participants and their support system about available resources, assists in making connections, and offers psychosocial education to encourage self-management.
• Establishes and maintains open and effective communication with the IDT and other involved community providers, providing appropriate information while maintaining confidentiality.
• Continuously evaluates and promotes participants’ ability to remain safely in the community in collaboration with other disciplines, coordinating facility placement if necessary.
• Participates in quality improvement studies and data collection as required.
• Attends and actively participates in IDT and program meetings, activities, and problem-solving endeavors, contributing to open lines of communication.
• Recognizes clinical or personal limitations by utilizing supervision when necessary.
• Understands and applies regulatory and procedural requirements of the social work discipline within PACE, as well as IOA’s policies and procedures.
• Remains current in the field of professional social work by attending continuing education and/or in-service training to increase knowledge, skills, and attitudes relevant to medical social work, social work core competencies, case management, gerontology, family, and community systems.
• Participates in and promotes ongoing efforts towards continuous quality improvement initiatives and Service Utilization Reviews.
• Actively incorporates the ethical standards of the National Association of Social Workers and upholds core values including service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence.
• Performs all other reasonably related responsibilities as assigned.

Requirements:

• Must hold an MSW (Master of Social Work) from an accredited school of Social Work.
• At least one year of professional experience working with frail elderly.
• At least one year of experience working in an interdisciplinary care model.
• Licensure is not required, but supervision towards LCSW (Licensed Clinical Social Worker) licensure is provided.

Background and Experience (Preferred):

• Experience with and understanding of the medical and psychosocial problems of functionally impaired adults and the frail elderly.
• Exceptional communication and presentation skills when relating to the frail elderly, functionally impaired adults, their support systems, and teams of health professionals.
• Detail-oriented with good problem-solving skills and the ability to prioritize multiple tasks.
• Computer literacy preferred.
• Bilingual Cantonese or Spanish preferred.

Compensation:

The compensation range for this position is $40.43 – $48.32 per hour. This range is not a guarantee of actual compensation, which depends on actual experience, education, and other factors. It does not include any additional equity, benefits, or other non-monetary compensation.