Overview Ensures quality delivery of social worker services and assists in providing home health care services that reflect the Agency’s philosophy and standards of home health care. Responsibilities • Assists in evaluating referrals for admission to the home health program: • Assists in identifying patients who would benefit from services. • Acts as a resource person to hospital social service departments, nursing personnel, and discharge planners to evaluate referrals as appropriate. • Assists in investigating the patient’s financial situation as appropriate. • Assists in identifying patients’ needs and in formulating an initial plan of care for those patients admitted into the Agency’s service. • Assesses the patient, his/her family, support system, and home situation, and identifies needs or potential needs. • Works with the nurses or other health team members and formulates a comprehensive plan of care to meet the patients’ needs. • Explores available community resources that might be helpful in meeting the patients’ needs. • Explores available community resources and assists patient in qualifying for eligible programs. • Assists patients in utilizing any resources that are available to obtain maximum benefit from the program. • Follows up Adult Protective Services referrals with letters to the Department of Social Services directors. • Counsels and supports patients. • Assists patients in utilizing or building support systems. • Assists patients and their families in dealing with the emotional aspects of their illnesses and conditions. • Assists patients and their families in accepting their medical condition and complying with medical recommendations. • Provides assistance to patients in formulating Advance Directives. • Participates in multi-disciplinary team meetings. • Reevaluates goals and plans of care and offers suggestions to meet patients’ needs in a better way. • Assists health team members with emotional factors related to patients’ health problems. • Acts as a resource person for health team members in planning patient care and offers suggestions as appropriate. • Maintains required medical records. • Documents observations made, and actions taken in a timely fashion using paper or electronic means. • Documents patients’ progress or response to care as appropriate using paper or electronic means. • Keeps physicians informed of patients’ progress. • Forwards appropriate documentation concerning patients’ progress and summary of care to physicians at regular intervals. • Discussed patients with physicians when appropriate to clarify goals and objectives and to clarify the plan of care. • Performs other duties as assigned by management. Qualifications • Holds Master’s degree from school of social work accredited by the Council on Social Work Education. • Has minimum of one-year experience as a social worker in a hospital, out-patient, nursing home, or home care setting. • Has a thorough knowledge of community resources. • Has good communication skills. • Is able to deal effectively with stress.