Provide care to a caseload of older adults and their families/caregivers in a variety of settings including, the PACE Day Health Center, participant’s homes, and care facilities.
Provide in-person, telephonic, and virtual supportive counseling to participants, families, and caregivers.
Conduct initial, bi-annual, and unscheduled comprehensive assessments of participants.
Develop and implement fluid, participant centered care plans.
Collaborate with the Community Resource Specialist to support participants and caregivers in completing their case management needs.
Work closely with the Behavioral Health Therapist and Chaplain to ensure that participant’s mental and spiritual wellness are supported
Attend daily meetings with the PACE IDT
Contribute to the problem-solving process of participant care issues using social work values and principles
Act as liaison between the IDT and caregivers/family
Orient participants, families, and caregivers to PACE services
Coordinate care with outside providers and programs
Play an active role in the end-of-life transition for participants, families, and caregivers.
Identify, organize, and implement support groups for participants and caregivers
Complete documentation in accordance with Upham’s PACE and CMS standards
Supervise Social Work Interns as needed
Present ethical dilemmas at quarterly Ethics Committee meetings.
Perform other duties as required by the position and/or as assigned by the Manager of Social Work
