POSITION SUMMARY: The Social Services Specialist I works with patients/residents and their family members/significant others within the facility through use of the psychosocial perspective identifying their strengths, social, emotional, and mental health needs along with providing, developing, and/or aiding in the access of services to meet those needs. The Social Services Specialist I shall provide patients/residents with the highest practical level of physical, mental, and psychosocial well-being and quality of life. Services are provided in accordance with the National Association of Social Workers (NASW) Code of Ethics and compliance with federal, state, and local guidelines and regulations, Genesis policies & procedures, and standards of care for specialty practice (Reference: Social Services Job Description Addendum Specialty Practice)..
1. Assists with planning and implementing a comprehensive Social Services program.
2. Reviews facility policies and procedures as part of the facility's interdisciplinary team to assure compliance with federal and state regulations.
3. Participates in Quality Improvement process as requested by the Social Services Director.
4. Understands and meets all government requirements for Social Services documentation.
5. Assures timely entries in the patients'/residents' charts to include, but not limited to: a Social History Evaluation & Assessment, a care plan to address strengths, problems, needs, and interventions, substantiation of psychosocial interventions, progress toward, and/or completion of goals, and transfers.
6. Consults with Director of Social Services and other departments regarding interdisciplinary issues.
7. Serves as an active contributor in designated center meetings at request of Social Services Director (Utilization Management, Customer at Risk, Care Planning, etc.)
1. Works with the interdisciplinary team to promote and protect resident rights and the psychosocial well being of all patients/residents. Prevents and addresses resident abuse as mandated by law and professional licensure.
2. Works with patients/residents, families, and significant others to provide support and information for taking a more proactive role in self advocacy to improve the quality of life/care for individual patients/residents.
3. Responds to issues identified by patients/residents and families to determine satisfaction with services.
1. Completes a comprehensive Psychosocial Assessment for each patient/resident that identifies social, emotional, and psychological needs and strengths. Assesses each patient/resident for discharge.
2. Conducts patient, family, and staff interviews and ensures that relevant MDS sections (i.e. cognitive, mood, behavior, patient goal setting) and Care Area Assessments are completed in accordance with regulation.
3. Participates in the development of a written, interdisciplinary plan of care for each patient/resident that identifies the psychosocial needs/issues of the patient/resident, the goals to be accomplished for those needs/issues, and the appropriate Social Services interventions.
4. Provides therapeutic interventions to assist patients/residents in coping with their transition and adjustment to a long-term care facility including the social, emotional, and psychological needs.
5. Provides support and education to patient/resident and family members/significant others to assist in their understanding of placement and facility issues in addition to referring them to the appropriate Social Service agencies when the facility does not provide the needed services.
6. Facilitates patient/resident transfer throughout the center to ensure a seamless transition and patient/resident adjustment.
7. Provides clinical interventions, staff support and education to address catastrophic events that occur during the patient's/resident's stay in the facility.
8. Participates as part of the interdisciplinary care team in providing interventions to resolve behavior or mood problems.
9. Works in tandem with community based providers' i.e. behavioral health and hospice providers to assure continuity of care.
10. Participates with the health care decision making process within the center.
11. Arranges and conducts patient/resident family meetings as needed. May facilitate family council.
1. Identifies patient/resident discharge goals at admission and documents initial discharge plan.
2. Works with patient/resident, family members/significant others, and interdisciplinary care team through care planning and utilization management throughout the course of the stay to identify strengths and needs to ensure an appropriate discharge plan is formulated.
3. As part of interdisciplinary team, identifies discharge teaching needs.
4. Responsible for communicating to center team members the estimated discharge date and updating Point Click Care.
5. Makes referrals as needed for post discharge care to appropriate agencies and suppliers.
6. Establishes relationships and maintains contact and referral flow with community based agencies/services for discharge planning.
7. As part of the interdisciplinary care team, identifies discharge teaching needs.
8. Initiates and participates in completion of Discharge Transition Plan & Discharge Packet materials and orienting the patient/resident and family around the process.
9. May be involved in contacting patients/residents post discharge to ensure successful transition.
1. Educates staff regarding the role of the social services in the facility and the psychosocial needs of the patients/residents and their families/significant others including the problems of aging and disability as requested by Social Services Director.
2. Participates in new employee orientation and supports the Nurse Practice Educator in regards to staff education (i.e. resident rights, grief/depression, and others) as requested by Social Services Director.
3. Educates patients/residents and families/significant others regarding their rights and responsibilities, health care decision making/advance directives, effective problem solving and the extent of community, health and social services that is available to them, including those necessary for effective discharge planning.