What You Will Do

• Assesses clients and/or family psychosocial status, social work needs and living conditions utilizing professional knowledge, skills of observations and interviewing skills.
• Establishes the social work component of the patient/family plan of care based on goals mutually acceptable to the client, family and significant others. Makes referrals to other community services, as necessary.
• Travels to patients' homes and/or other facilities with varying environments (e.g., elevated buildings, walk-ups, care facilities, single/multiple family homes, presence of pets, etc.) using approved transportation options to deliver direct service to the client.
• Provides psychosocial work services to patient and/or family, including short-term individual counseling, community resource planning, and crisis intervention. Responds to emergent psychosocial patient and family needs, as requested.
• Provides advocacy to patient and/or family, e.g., assistance in obtaining entitlements and community services.
• Provides social work services in accordance with VNS Health policies, practices, procedures and Standards of Social Work Practice, which may require standing, stooping, sitting, crouching, bending and stretching to deliver patient care, as needed.
• Initiates and maintains verbal and written communication according to VNS Home Care policy, including the preparation of clinical and progress notes, to ensure optimal quality care.
• Manages social work planning for a caseload of patients prescribed by the physician and other team members from assessment to discharge. Maintains productivity sufficient to meet program goals.
• Assists the physician and other team members in understanding the significant social and emotional factors related to the patient's health problems.
• Participates in the development of treatment plans and revises the goals as needed. Coordinates approaches to patient and/or family care with other team members.
• Consults with and educates the patient and family regarding the treatment plan, self-care techniques and prevention strategies.
• Utilizes appropriate community resources and serves as a liaison between VNS Health and other community agencies.
• Participates in discharge planning.
• Assumes responsibility for continued professional growth, such as in-service programs.
• Transports and utilizes VNS Health designated/supplied carrying case weighing up to 30 lbs. (as needed) to and from patient homes/care facilities, VNS Health offices and other locations.
• Acts as a resource to VNS Health staff.
• Participates in special projects and performs other duties as assigned.