Social Worker

Saint Johns Communities
Milwaukee WI
Social Worker Care Neighborhoods
JOB OBJECTIVE:
Reporting to the Care Neighborhoods Administrator theCare Neighborhoods Social Worker supports the provision of care coordination in a manner that recognizes the resident family medical team and neighborhood staff as essential partners in the residents care. The Care Neighborhood Social Worker will work with residents in the care neighborhoods by identifying their psychosocial mental and emotional needs along with providing developing and/or aiding in the access of services to meet those needs. The Care Neighborhoods Social Worker serves as Admissions Coordinator for the Care Neighborhoods.

ESSENTIALDUTIES:

Job Duties
Admission Coordination/Admissions

1. The Care Neighborhoods Social Worker serves as Admissions Coordinator and isresponsible for managing the entire admission process for all potential residents in the Care Neighborhoods including but not limited to evaluating medical needs reviewing insurance coverage conducting tours interviewing prospective residents and their families and ensuring all necessary paperwork is completed to facilitate a smooth transition into the neighborhoods while adhering to relevant regulations and maintaining positive relationships with referral sources. Other functions as requested by the interdisciplinary team.
2. Supports viability of the Care Neighborhoods through stable and sustained occupancy. Anticipates openings and works to proactively to fill available beds. Alerts care neighborhood administrator and nurse managers of potential openings. Works with the Marketing team to garner external referrals in times of need.
3. Maintains knowledge of bed status and potential admissions in the care neighborhoods and provides daily updates in stand up. Keeps bed tracker and referral tracker up to date.
4. Ensures that the admission packet is understood and signed by residents or responsible party upon admission to the care neighborhoods. Completes and processes all admission paperwork with residents and/or responsible parties.
5. Develops a comprehensive social history and completes a psychosocial assessment that includes the residents problems and strengths and preferences for residents admitted to the care neighborhoods.
6. Orients care neighborhood residents and families to Saint Johns - its services service limitations and residents rights.
7. Helps residents and their families (in their social racial ethnic and cultural context) cope with the immediate effects of the decision to move to Saint Johns or to transfer within the continuum of care at Saint Johns. Provides daily visits/contact to newly admitted residents to guide their acclimation to their new surroundings and provide support.
8. Follows and monitors hospitalized independent living residents for potential admission to the care neighborhoods.

Communication/Planning/Documentation

1. Completes comprehensive written admission quarterly and change of condition assessments utilizing and expanding on the State and Federal minimum standards (Minimum Data Sets) within the electronic medical record.
2. Develops and maintains a working relationship with the interdisciplinary team.
3. Coordinates care conferences in the care neighborhoods to discuss and coordinate the care plan/individual service plan allowing for open communication collaborative decision-making and ensuring the best possible quality of life for the resident by addressing their needs and concerns
4. Works directly with residents and families on Advanced Directives in the care neighborhoods. Ensures any Advanced Directives are in place per facility policy and completes the activation process when indicated.
5. Assures that progress notes meet the standards established by Federal and State governments including resident status response to and evaluation of social service programs and activities within required timeframes.
6. Serves as a resource to residents/families on Medicare and Medicaid benefits. Assists with the application for benefits.

Psycho-social and Behavioral Health

1. Facilitates resident/family access to resources to support their psychosocial/emotional needs such as the Alzheimers Support Group and Emotional Support resources recommended by Saint Johns.
2. Conducts depression dementia or other types of screenings as needed.
3. Helps residents and family prepare for and cope with losses including aging and death.
4. Coordinates access to behavioral health services.
5. Manages concerns and grievances.

Discharge Planning

1. Isresponsible for managing the transition of residents leaving the care neighborhoods including coordinating necessary post-discharge services communicating with family members arranging transportation and ensuring a smooth handover to community-based care providers all while advocating for the patients needs and ensuring their safety and well-being after discharge
2. Provides linkage with appropriate community resources by maintaining knowledge of other systems making referrals and identifying unmet needs (e.g. recreational transportation adaptive phone equipment financial questions crisis management services durable medical equipmentetc.) inside and in the greater community.

Professionalism

1. Maintains the confidentiality of proprietary business financial health personal or other information concerning residents employees consultants prospects and operations and where appropriate complies with the Health Insurance Portability and Accountability Act (HIPAA) as well as organizational and departmental standards.
2. Assures that all resident rights are maintained. Report any violations of suspected deviations according to Saint Johns policy.
3. Leads investigations of allegations of any form of Misconduct according to State and Federal regulations. Documents findings and reports to the State as required by law.
4. Works cooperatively with residents clients families volunteers visitors and all levels of staff throughout the organization. Accepts delegation from multiple disciplines.
5. Completes all mandatory in-services within established timeframes; attends all meetings seminars etc. as directed.

All Employees Must Foster Person Centered Care/Professional Integrity and Responsibility

1. Act with honesty and openness in all resident/family/ responsible party and employee contacts. Function as Saint Johns Communities Ambassadors to maintain a working environment that values respect fairness inclusiveness and integrity. Promote a responsible workplace in recognition and support of the boundaries of people with whom we work and serve.
2. Demonstrate commitment to the person-first philosophy that gives residents the power of choice. Function as a community member within the principles and practices that guide care and services through knowing and honoringthe person before the task. In this vein we will:

• Foster relationships between residents family and staff.
• Know each person as an individual who can and does make a difference.
• Nurture the spirit as well as the mind and body.
• Promote growth and development for all.
• Create an environment that meets the physical social emotional intellectual spiritual and occupational needs of individuals and the community.

KNOWLEDGE SKILLS ABILITIES QUALIFICATIONS:

Knowledge:

1. Familiar with State and Federal regulations/guidelines for primary work area: Skilled Nursing Facility (Windsor); CBRF (Stratford and Canterbury) and RCAC (Towers).
2. Knowledge of community services such as home health and proven skills in discharge planning.
3. Understands the MDS system and is able to complete the Social Work component (Windsor).

Skills:

1. Possesses basic computer skills with some proficiency in the use of Microsoft Outlook Word and Excel.

Abilities:

1. Demonstrates dependability and reliability in adhering to an established work to work flexible hours to meet scheduling requirements.
2. Demonstrates performance efficiency in managing workload in order to meet established deadlines. Able to adapt to changing organizational needs.
3. Displays excellent written and verbal communication skills. Knows and follows existing lines of communication and a warm cheerful caring manner when interacting with residents families co-workers and other guests at Saint Johns.
4. Must be professional in actions dressappropriately to the position have excellent customer serviceskills and desire to work with and serve older adults.
5. Must demonstrate the ability to comprehend and follow established procedures. Able to multi-task andwork independently while performing various job duties.
6. Must have demonstrated ability to identify a residents social/emotional needs and be able to intervene effectively.

Qualifications:

1. Must be a graduate of an accredited School of Social Work Services and currently licensed as a Social Worker in the State of Wisconsin. Masters degree in social work preferred.
2. Must have at least 2 years of experience working with a geriatric/rehabilitation population. One yearexperience in a Medicare and Medicaid certified long term care facility with strong knowledge of OBRA guidelines.
3. Must have experience working with dementia and behavioral health residents/patients.
4. Must be able to read speak and write English.

WORK SETTING/ENVIRONMENT:
(The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.)

Work is performed indoors. The office and building are well lit and clean with some exposure to dust. Heat air conditioning and humidity are controlled by the buildings central system with a temperature variance of not more than 7 degrees on either side of the norm of 72 degrees.

EQUIPMENT USED: Copy postage FAX machines stapler file cabinet and desk phone pens.

PHYSICAL/SENSORY/COGNITIVE REQUIREMENTS TO PERFORM ESSENTIAL JOB FUNCTIONS
The physical demands described here are representatives of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The phrases occasionally regularly and frequently correspond to the following definitions: occasionally means up to 1/3 of working time regularly means between 1/3 and 2/3 of working time and frequently means 2/3 and more of working time.)

Strength:Must be able to occasionally lift objects weighing up to 10 pounds and push wheelchairs with residents of different weights.
Manual Dexterity: Must be able to frequently perform moderately difficult manipulative tasks.
Coordination:Must be able to frequently perform tasks that require action of muscles or groups of muscles and occasionally perform tasks which require hand/eye coordination.
Mobility:Must be able to frequently navigate throughout work area.
Speech: Must be able to frequently articulate clearly and precisely.
Emotional Stability: Must be able to frequently deal with high levels of stress created when acting as a resident advocate and involvement with families staff and governmental and community agencies.
Vision:Must be able to frequently see objects closely to read and write; must be able todiscriminate colors to interpret emergency lights.
Hearing:Must be able to continuously hear normal sounds and voice patterns with occasional background noise.
Smell:Must be able to use sense of smell to detect smoke or odors not appropriate for the nursing home.
Concentration:Must be able to frequently concentrate on fine detail with constant interruptions.
Attention Span:Must be able to frequently attend to tasks/functions for more than 60 minutes at a time.
Conceptualization:Must be able to frequently understand and relate to the theories behind several related concepts.
Memory: Must be able to frequently remember verbal and written tasks/assignments given at the beginning of a period of time and extending over several days and occasionally remember multiple verbal and written tasks/assignments.

EMPLOYEE RESPONSIBILITY IN AN EMERGENCY: Must know understand and comply with all emergency procedures and be able to assist with resident evacuation if necessary and all safety security infection control and hazardous materials policies and procedures.

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