Job Description

JOB SUMMARY

The Social Worker position offers a unique opportunity to help build the first PACE (Program of All-Inclusive Care for the Elderly) program in the District of Columbia within the framework of a supportive, innovative, and expert leadership team and company.

As a Social Worker at Edenbridge PACE at Skyland Town Center, you will play a critical role in providing essential support to participants and their families. The Social Worker is responsible for assessing psychosocial needs, developing care plans, coordinating services, and advocating for participants in the Program of All-Inclusive Care for the Elderly (PACE).

ESSENTIAL DUTIES AND RESPONSIBILITIES

 

• Responsible for initial, 6 month, change of condition, and annual assessments
• Presents assessments at care plan conferences with the goal of providing a foundation for the care plan and team discussion of participant issues
• Provides ongoing support and education to participants and families/caregivers covering a variety of issues, including but not limited to the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics, housing, behavioral health concerns, substance dependency issues, and fraud and abuse (experience with APS and DBH a strong plus)
• Provide brief, solution focused therapy and group psychoeducation/treatment related to chronic medical conditions 
• Provide crisis intervention and triage with appropriate interventions
• Coordinates admissions/discharges to contracted facilities for temporary respite and permanent placement 
• Initiates nursing home co-pay status upon discharge from team and supervisor when skilled facility placements become permanent
• Performs home visits to participants in ward 7 & 8 as needed to assess living environment and support system
• Provides referrals and assessments with contracted assisted living residences 
• Facilitates participant moves between residences or assisted care facilities
• Coordinates hospital discharges in communication with attending medical team members 
• Initiates referrals to external resources with community agencies
• Advocates for participants to ensure their voices are heard in the development and implementation of care plans.
• Works closely with community resources and agencies to enhance participant support.
• Maintains current documentation in participant medical records including initial assessments (narrative, problem lists, assessment forms); reassessments (updated problem lists and chart note); change of status; temporary or permanent placements; hospital discharges; home visits; and other significant events
• Engages in community outreach to enhance awareness of the PACE program and its social services
• Additional responsibilities will be added at managers discretion, as career growth opportunities and responsibilities are constantly arising in our flexible and start-up environment

QUALIFICATIONS

• Master’s Degree in Social Work 
• Current state licensure as a Masters Social Worker (MSW) in Washington, DC or ability to acquire license within 6 weeks
• A minimum of one year of experience working with frail or elderly population is required
• Experience working on a multidisciplinary team preferable 
• Must be fully vaccinated, including against Covid-19, and free of communicable diseases
• Must have a current driver’s license and driving record must be in compliance with Company policy 
• Experience documenting in an Electronic Health Record preferred

  Ability to collaborate effectively within an interdisciplinary team.

Learn more at:  

edenbridgehealth.org

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