Job Description

Assumes responsibility for the ongoing interdisciplinary assessment and development of the individualized plan of care in partnership with the patient, representative (if any), and caregiver(s).

Assesses the psychosocial status of patients related to the patient’s illness and environment and communicates findings to the registered nurse.

Carries out social evaluations and plans intervention based on evaluation findings.

Provides patient, caregiver, and family counseling.

Providing services that are ordered by the physician as indicated in the plan of care.

Communicates with the physician who is responsible for the home health plan of care and other health care practitioners (as appropriate) related to the current home health plan of care.

Assists physician and other teams members in understanding significant social and emotional factors related to health problems.

Prepares clinical notes on all patients referred to social work.

Provides information and referral services for Organization patients and families/caregivers regarding practical and environmental needs.

Provides education to patients or families/caregivers and community agencies.

Serves as liaison between patients or families/caregivers and community agencies.

Maintains collaborative relationships with Organization personnel to support patient care.

Maintains and develops contracts with public and private agencies as resources for patient and organization personnel.

Participates in the development of the total plan of care and case conferences as required.

Participates in discharge planning.

Supervises, as directed, any Social Worker Assistants (SWA’s).

Participating in the HHA's quality assessment and performance improvement program and HHA-sponsored in-service training.