Case Manager-Social Worker
Current-Performed in-home care management visits to assess and impact social and behavioral status -Worked closely with Care Team to ensure continual progress on all care management goals -Assessed social determinants of health needs and develop a plan for addressing them -Performed behavioral, environmental, and social support assessments and surveys as needed -Delivered individual, family and group education on living with chronic illness -Engaged family and social support groups in the education and care of patients -Assessed patients and refer to behavioral health specialists if diagnosis and treatment needed -Helped patients to understand, accept and follow medical and lifestyle recommendations -Served as the point of contact for social and behavioral questions from patients -Facilitated conversations around and consideration of proactive care decisions, especially relating to transplantation, home modalities and AV fistula placement -Initiated patient relationships through enrolment and onboarding processes -Reviewed and documented patient updates and progress in care management platform -Identified, vetted, and built relationships with local Community-Based Organizations -Introduced patients to appropriate resources and act as the patient advocate -Served as subject matter expert on social determinants for other members of the Care Team