Job Summary:

Provides a wide range of clinical social work services in a primary care or home health setting, including support and consultation to

care team in managing patients. Evaluate psychosocial assets and deficits for the purpose of enabling the pt to maintain the greatest

level of independence. Coordinates with others to establish a plan of care. Provides short term counseling, teaching and brokering with other resources for care giving needs.

Essential Responsibilities

-Provide appropriate social work interventions to all age patients and their families including but not limited to psychosocial assessment, brief individual or family, advocacy, linkage, referral, group work, case coordination, and long-term care planning and placement.

-Consultation and coordination with multidisciplinary team of care professionals and primary care site medical/nursery staff, to include family conferences, care conferences, team meetings and etc.

-Assesses patient and family needs for care and communicates with other health care providers appropriately. Collects data relevant to visit with ongoing assessment throughout the duration of care. Evaluate psychosocial assets and deficits for the purpose of enabling the pt to maintain the greatest level of independence.

-Evaluates patients/family needs through timely assessment, communication and observation. Modifies plan of care through assessment based upon patient/care systems response.

Provides crisis intervention, grief/bereavement counseling, problem solving, stress reduction and developing healthy coping strategies to patients in home based, clinic, or inpatient care setting. Conducts comprehensive psychosocial assessment and partners with patient to identify needs and develop and implement individual plan of care based on mutually agreed upon goals in order to assist patients and families to cope and/or restore social, emotional, financial and environmental factors which affect and/or are affected by illness. Responsible for implementing this plan. Discuss options for care proactively including Kaiser resources and external community/government resources to assist patient and family in developing short- and long-term care plans as appropriate. Team with other disciplines in assessing, planning and providing services for patients utilizing biopsychosocial information. Assist patient in advocating for self to receive appropriate services within Kaiser and in the community. Takes, reviews, evaluates and prioritizes referrals and is responsible for daily scheduling of visits. Identifies appropriate levels of care and facilities for patients and obtains placements, where applicable. Collaborates with internal and external resources in Kaiser and the community to meet mutually agreed upon goals and objectives. Provides information and referral to community resources as requested. Coordinates exchange of information between Kaiser, families, members, and care facilities (including adult family home, assisted living and LTC/skilled nursing facilities). Determines application of Kaiser, Medicare and/or Medicaid benefits to specific patient situations. Assists in coordinating communication between home health/hospice, clinics, hospitals, and field staff to triage psychosocial needs of members. Performs other related duties as necessary.