Pace Place- Master's Level Social Worker (MSW)

The Pace Place helps older adults stay safe, healthy, and independent at home. We are North Florida’s only all-inclusive senior care program through PACE (Program of All-Inclusive Care for the Elderly).

• Job Summary:

Under the supervision of the Center Manager plans, organizes, and implements social work services for PACE Partners participants and families. Responsibilities include but are not limited to, participant social work assessment; treatment; and teaching and counseling of participant, caregiver, or other appropriate representatives/family to maintain participant support in the community. The Master’s Level Social Worker (MSW) interventions may also include individual participant contacts; appropriate collateral contact; participant and family education, assessment, and counseling; assistance with locating resources; addressing mental health needs as they arise; ongoing case management; advocacy to ensure participant and caregiver needs are met and addressed; and disenrollment procedures. The MSW is the liaison between the interdisciplinary team, caregiver representatives, and community agencies.

Shift: Mon - Fri day shift with on call rotation

$2500 Sign on bonus offered

• Qualifications and Requirements:

Education/Training/Certifications

· Master’s degree in Social Work from an accredited school of social work by the Council on Social Work Education

· Member of the Academy of Certified Social Workers (ACSW) or other NASW- recognized certification preferred

· Current driver’s license and proof of active auto insurance

· BLS, First Aid, and CPR certification helpful

Experience

· Two-years of experience working on an interdisciplinary team in a hospital, nursing home, long-term care facility, or community-based setting is preferable

· Minimum of one-year working with a frail or elderly population

Skills and Knowledge:

· Familiarity with the psycho-social issues of the frail and chronically ill and their caregivers

· Ability to provide psychosocial assessment and individual, family, and group counseling

· Ability to maintain accurate records and to prepare clear and concise reports, correspondence, and other written materials

· Good public speaking skills with all size groups

· Effective verbal and written communication skills

· Demonstrated ability to work in an interdisciplinary team setting

· Advanced computer literacy including Microsoft Word, Excel, PowerPoint, and Outlook

• · Work Environment: Employee must be able to work effectively within an interdisciplinary team model, interfacing and collaborating with a wide range of clinical and social services disciplines who work together to manage the PACE Partners participants' care. The work setting is in an Adult Day Health Center and primary care clinic environment with moderate noise levels and controlled temperatures.
• Duties and Responsibilities:

· Perform in-person initial assessments for enrollment of potential PACE Partners participants to obtain a complete psycho-social history, to include descriptions of cognitive status, social supports, family dynamics, mental health and substance dependency, and other current issues and needs

· Collaborate with the interdisciplinary team to develop a comprehensive care plan for each participant

· Conduct in person reassessments of enrolled participants every six months and as

· needed when participants’ conditions change

· Maintain regular attendance at and participate in daily Interdisciplinary Team meetings, communicate participant changes, and collaborate with team members in care planning decisions and coordination for 24-hour care delivery

· Act as liaison with participant, caregivers, and community agencies regarding orientation to and ongoing relations with Interdisciplinary Team, day center, and other PACE Partners employees

· On an annual basis (during annual or semiannual reassessment) presents the written participant rights documentation to assigned participants and or caregiver

· In the event the participant is unable to understand the information, the social worker will ensure the caregiver or representative understands the participant rights

· If there is a language barrier, the Social Worker will use an interpreter

· Provide ongoing support, counseling, and education to participants and family regarding a variety of issues, including but not limited to the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics and changing roles, PACE Partners model and PACE Partners health services

· Work proactively to maintain participant housing through intervention with participant, caregivers, and housing

· Assist participant to function at most independent community level possible

· Present requests to Interdisciplinary Team (IDT) for and coordinate admission/discharge to contracted facilities for temporary respites and permanent placement

· Perform home visits quarterly, or as needed, to assess living environment and support system

· Act as facilitator for meetings with participant, family, caregivers, and community agencies to clarify or problem solve issues, including plan of care. Mediate discussions between all parties

· Provide referrals to subsidized housing and assisted living residences

· This may involve completing applications, obtaining medical records, accompanying participants to interview assessments and tours if participant has no other support systems

· Perform visits at hospital within 24-hours of admission or on Monday if participant is admitted on Friday or weekend.

· Coordinate hospital discharges in conjunction with interdisciplinary team and communication with attending physician

· Communicate with family or caregivers frequently and as needed to update

· If end of life care is appropriate, actively provide emotional support, grief counseling, education, and funeral/financial planning referral. Facilitate end of life or nursing home placement as needed

· Initiate referrals to external resources with community agencies such as Adult Protective Services, Housing Authority, or public utility companies

· Advocate for participants with these entities for purposes of maintaining community stability

· Assist participants and caregivers to complete Medical Durable Power of Attorney (MDPOA), Proxy, and Do Not Resuscitate (DNR) directives as needed

· Attend and actively participate in a variety of organizational meetings related to participant care or daily operations, in-services, and community agency meetings.

· Act as a resource to other team members and day center staff regarding topics such as dementia, difficult behaviors, and difficult personalities.

· Complete all documentation of clinical service in participants’ medical records, including initial assessments; reassessments; change of status; temporary or permanent placements; hospital admissions and discharges; home and nursing home visits; and other significant events according to PACE Partners documentation requirements.

· Assist participants with Social Security Income (SSI) and Social Security Disability Insurance (SSDI) application process as needed.

· Assist participants and caregivers in filing grievances and appeals.

· Assist participants and family in keeping resources within guidelines for Medicaid eligibility and assistance if needed with annual Medicaid application.

· Assist participants disenrolling from PACE Partners in coordinating insurance and referrals for other community or facility-based services as desired by the participant.

· In the event of termination of PACE Partners, the social worker will act to coordinate the transitional care necessary to ensure continuation of care during and after termination. Assist participants in obtaining reinstatement in conventional Medicare and Medicaid benefits, transition to other care providers, make referrals to other community-based or facility-based providers, assist in providing the participants’ medical records to new providers with participant approvals.

· Act only within the scope of his or her authority to practice.

· Follow all Policies and Procedures and OSHA safety guidelines.

· Protect privacy and maintain confidentiality of all company procedures, results and information about employees, participants, and families.

· Practices standard precautions.

· Maintain safe working environment, following PACE Partners safety policies and procedures.

· Participate in and support Quality Improvement initiatives

· Participate in continuing education classes and any required staff and training meetings.
Maintain professional affiliations, required certifications and continuing education requirements.

Job Type: Full-time

Pay: $59,000.00 - $70,000.00 per year

Benefits:

• Dental insurance
• Employee assistance program
• Flexible schedule
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Referral program
• Retirement plan
• Tuition reimbursement
• Vision insurance

Education:

• Master's (Preferred)

Ability to Commute:

• Jacksonville, FL 32205 (Required)

Ability to Relocate:

• Jacksonville, FL 32205: Relocate before starting work (Required)

Work Location: In person