Description

JOB TITLE: Facilities Social Worker DEPARTMENT: Clinical Services

REPORTS TO: Team Leader

SUPERVISES: NA

Position Summary

The Social Worker provides emotional support, counseling, and resource coordination to patients, families, and caregivers in home care settings and healthcare facilities, including assisted living facilities, personal care homes, skilled nursing facilities, and independent living facilities. The Social Worker plays a vital role in ensuring patients' psychosocial, emotional, and practical needs are met while developing, maintaining, and supporting strong working relationships with facility staff and administrators.

Responsibilities

DUTIES AND RESPONSIBILITIES

Facility-Based Social Work Services

• Conduct psychosocial assessments for patients in assisted living facilities, personal care homes, skilled nursing facilities, and independent living facilities.
• Provide counseling and emotional support to patients and families coping with illness, disability, or end-of-life issues.
• Advocate for patient rights, preferences, and quality-of-life improvements within facility settings.
• Assist patients in adjusting to facility life, addressing concerns about autonomy, relationships, and transitions.
• Educate patients and families on advance care planning, advance directives, and decision-making options.
  
  

Coordination & Collaboration with Facility Staff

• Develop and maintain strong working relationships with facility administrators, nurses, and care teams to ensure comprehensive care.
• Work closely with facility social workers, case managers, and discharge planners to coordinate care transitions.
• Attend facility care conferences and interdisciplinary team meetings to discuss patient needs and psychosocial interventions.
• Act as a liaison between patients, families, hospice teams, and facility staff to address psychosocial concerns.
  
  

Resource & Care Planning

• Assist families in navigating healthcare options, insurance coverage, and long-term care planning.
• Provide guidance on financial resources, Medicaid/Medicare benefits, and community support services.
• Help patients and families access mental health support, grief counseling, and respite care services.
• Develop personalized care plans that address social, emotional, and financial concerns while aligning with the patient's goals.
  
  

Patient Advocacy & Emotional Support

• Support families in making difficult healthcare decisions, including transitions to higher levels of care.
• Provide crisis intervention and coping strategies for patients facing serious illness, loss, or end-of-life concerns.
• Facilitate support groups and educational sessions for facility staff, residents, and families on topics such as grief, coping, and caregiver stress.
• Advocate for patients' dignity, respect, and comfort in all facility interactions.
  
  

Compliance & Documentation

• Maintain accurate and timely patient records and documentation according to hospice, facility, and regulatory standards.
• Ensure all interventions align with state and federal regulations for hospice and long-term care settings.
• Comply with HIPAA and patient confidentiality standards when sharing information with facility staff.
  
  

Other duties as assigned.

Qualifications

QUALIFICATIONS

• Licensed Master Social Worker (LMSW), with an unrestricted license in the State of Texas.
• Master of Social Work (MSW) degree from a school of social work accredited by the Council on Social Work Education.
• Valid Texas driver’s license, auto liability insurance and safe driving record. (if required for the position)
• Knowledge of hospice federal and state regulations preferred.
• Strong computer skills including knowledge of and experience with Microsoft Office products and experience with electronic medical records (EMR).
• One year experience in a healthcare environment (including volunteer or intern experience).
• Experience in hospice, home-health, or hospital social work preferred.
  
  

REQUIRED SKILLS/ABILITIES

• Strong interpersonal and communication skills.
• Compassionate and patient-centered approach to emotional support and counseling.
• Ability to navigate complex care situations, advocate for patients, and coordinate resources.
• Adaptability to various care settings, facility policies, and interdisciplinary teams.