Community Care Social Worker
Current- Responsible for the proactive case management of acutely and chronically ill patients receiving care in a home-based setting- Conduct a comprehensive biannual health and psychosocial assessment of participants' medical needs, diagnoses, functional and cognitive abilities, and environmental and social needs, to determine which services are required to meet the participants' needs and preferences in the community- Collaborate on a multidisciplinary team to create a Plan of Treatment that reflects a comprehensive needs assessment, intervention development, and ongoing support for each participant- Implement the Plan of Treatment, including identifying service providers and community resources to help ensure the timely, effective, and efficient mobilization and allocation of services- Monitor the quality of authorized services by maintaining ongoing monthly contact with HCBA Waiver Program participants to monitor for changes in health, mood, social integration, functionality, and overall well-being- Monitor the delivery of HCBA Waiver services to ensure participants are receiving services as authorized in their Plan of Treatment- Mitigate risk and minimize disruption in services- Develop resources and refer patients and families to appropriate community agencies and act as a liaison and advocate for participants- Provide information, education, counseling, and advocacy to, and on behalf of, participants- Function as the point-of-contact for participants, their legal representatives, circles of support, and/or primary care physicians- Maintain accurate HCBA Waiver Program case management records and timely documentation standards
