The Medical Social Worker (MSW) provides medical social services, under physician orders, in the home care setting. Responsibilities include assessment of social and emotional factors, the provision of short term therapy, counseling for long range planning, and supportive counseling geared to restoring patients to their optimal level of social adjustment. Knowledge of community resources is essential. Population served: Diverse population of all ages residing in Dutchess County.

Responsibilities:

Clinical Skills and Knowledge

• Demonstrates proficiency in assessment of client's social and emotional status using effective interviewing skills.
• Identifies client and family needs and priorities of care.
• Recognizes and documents changes in general physical and mental condition of client; reports to physician and case manager immediately.
• Implements individualized plan of care and discharge plan including coordination with other disciplines.
• Evaluates outcomes of plan-of-care and alters plan as needed.

• Set prioritizes based on patient need and patient response and outcomes.
• Recognizes and intervenes in situations related to patient safety
• Adheres to agency and hospital's policies and procedures. Supports and participates in changes affecting the department (policy revisions, special projects.

• Engages patient and family in treatment plan.
• Mediates between patient, family and agency staff to develop discharge plan
• Provides supportive counseling to reduce anxiety and prepare patient and family for discharge and/or referral.
• Counsels patient and/or family regarding relationship problems, adjustment to illness, and improving social functioning.
• Assists clients and/or family to resolve environmental and personal difficulties that impact the success of the medical treatment plan (inadequate food, medical supplies).
• Establishes linkages with community resources as indicated, such as food stamps, Office of Aging, Meals on Wheels, transportation, personal alert system, etc.
• Assists client access federal and state funded financial entitlements such as Medicaid, SSI, etc. Facilitates application process by meetings with family and social services, additional phone calls to research
• Provides short term therapy to resolve conflict related to chronic or terminal illness.
• Counsels for long range planning, which may include referrals to Hospice, nursing home placement, etc.
• Conferences with case manager and other interdisciplinary team members per policy. Communicates patient progress toward goals every 2 weeks with appropriate team members 95% of time. Proactively requests teleconference to share appropriate issues with patient obstacles to goal achievement.

• Records and submits initial psychosocial assessment within two working days.
• Documents ongoing evaluations, revised goal setting as needed, and submits documentation per policy.
• Submits activity sheets weekly to facilitate payroll.

• Functions and upholds the professional standards of the medical social worker role via evidence based practice, interactions and appearance. Identifies potential areas of research Helps participate in orientation and precepting of staff as needed
• Accepts accountability for own practice. Researches and assists in the development of staff education tools. Identifies potential learning needs of staff.
• Participates in 15 contact hours of education. Participates in additional 15 contact hours or 12 academic credits and shares knowledge with staff.

• Minimum of two years experience beyond certification.
• Experience in a mental health or hospital setting.

• Master's in Social Work degree

• Licensed Certified Social Worker in New York State

• If applicable, the individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.
• New York State driver's license
• Ability to work both independently and with the multidisciplinary health care team.
• Excellent communication skills.

About Us:

MidHudson Regional Home Health