Performs in home health patient assessments, care plan
formulation and direct short term interventions that aid the
patient and family in meeting health related needs in the home
setting. Responsible for the most complex cases. Completes duties
in an effective and timely manner in collaboration with the home
health care team and community resources.
Provides social work services to individuals or groups
including: screening, psychosocial assessment, discharge planning,
determination of social work goals, appropriate concrete and/or
therapeutic interventions and follow-up. Exercises a substantial
degree of professional judgment, recognizing deviations from the
usual patient/family functioning, anticipating problems and taking
measures to maximize coping capabilities.
Conducts initial assessment and establishes a plan of care
through psychosocial, financial, functional, and environmental
data; establishes and follows a plan of care, which identifies
problems and evaluates outcomes. Provides ongoing assessment of
patient/family needs and applies appropriate interventions. Updates
and revises plan of care as indicated.
Plans for discharge from medical social services according to
organization standards and utilizes internal systems and community
resources to assure patient/family needs are being met.
Implements interventions substantiated by assessment as
appropriate to the needs of the patient/client system and
consistent with available resources. Initiates and coordinates
interventions with the activities of other members of the health
care team. Collaborates with community agencies and institutions to
plan continued care and to coordinate interventions related to
finances, housing, childcare, family discord and other psychosocial
problems. Provides crisis intervention services.
Documents activity according to department and program protocols
or standards. Maintains and updates patient records according to
organization, state, and federal guidelines.
Assists with managing utilization of resources especially as
related to patients with complex continuity of care needs.
Provides education to patients/families regarding Advance
Directives for health care decision-making. Assists with execution
of these documents as appropriate.
Communicates effectively with patients, family, other members of
the health care team and community agencies and facilities
resolution of issues which could impact on continuity of care
(e.g., prior-approvals, application requirements, transfer
paperwork). Communicates with physician, care coordinator, other
team members to collaborate and update plan of care. Provides
support to patient's family members in the case of a patient's
Establishes effective professional relationships, positively
representing the social work profession throughout the organization
and in the community. Promotes constructive approach to problem
solving. Adheres to the professions Code of Ethics; consistently
practices within a framework guided by ethical principles.
Part-time position, mainly M-F 8am-430pm. Rotation of on call on
Weekends, evenings and holidays to meet department needs.
Individual to work 4 days one week and 3 days the next. Focus on
the Social work needs of hospice and palliative care
Licenses & Certifications
Social Worker license issued by the state of Wisconsin, and
A valid drivers license issued by the Division of Motor
Master's Degree in Social Work.
Required Functional Experience
Typically requires 2 years of experience in social work that
includes experiences in a home care or hospice environment.
Knowledge, Skills & Abilities
May be required (based on work location) to have a current
driver's license granted by the state of residency with a driving
record that meets Aurora fleet safety standards and proof of
automobile liability insurance.Must possess exceptional assessment
skills.Demonstrates exceptional understanding of family dynamics
and psychosocial issues related to disability, acute and chronic
illness and problems associated with advanced age.Ability to
provide short-term counseling to patients and their
families.Exceptional collaboration skills, advocacy abilities and
ability to perform as a team player.Exceptional knowledge of
community resources and effective in accessing these resources.Must
possess above average time management skills to comply with
productivity standards, patient needs, regulatory requirements and
communication needs.Intermediate computer skills including word
processing, presentation applications and electronic mail.