Social Worker - Primary Care At Home

The Licensed Social Worker- Home-Based Services will provide services to adult and geriatric homebound patients in their residences and via telehealth. This role requires travel to patient homes and the ability to work effectively in a home-based care setting. The Social Worker reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards. Responsibilities: • Provide social work services to adult and geriatric patients in their residences and via telehealth. • Travel to patient homes to deliver services. • Work in patient residences, which may include private homes, group homes, or assisted living facilities, and adapt to a variety of environmental conditions commonly encountered in the home setting, including pets, pet dander, dust, smoke, noise, clutter, varying indoor temperatures, and weather conditions during travel. • Maintain effective communication and coordination with patients, families, and care teams. • Ensure services are provided in accordance with professional standards and organizational requirements. • Collaborates and participates in the coordination of screening, assessment, and discharge planning activities in high risk patients and their families with complex psychosocial and economic needs. • Utilizes expertise and problem solving skills to achieve optimal clinical outcomes within effective resources and timeframes. • Promotes a seamless and safe discharge throughout the continuum of care • Collaborates with the care team for discharge planning and community linkage for patients and families with complex social, economic, and emotional needs. • Participates in care conferences and unit rounds. Keeps all members of the care team apprised of the current state and plan of care. • Develops positive relationships with co-workers, members of the care team, and community resources. • Collaborates with care team members to identify at risk populations and opportunities to improve care delivery and on-going support, thus increasing efficiencies and effectiveness. • Makes timely and appropriate referrals to ancillary support staff in order to facilitate progress toward a safe discharge. • Partners with the post-acute care providers and shares appropriate and pertinent information in order to create a seamless and safe discharge plan. • Identifies, assesses and responds to patient and family needs, incorporating age specific developmental, psychological, cultural and spiritual needs. Emphasis is placed on addressing the social and emotional needs of the patient and family that may impact on the patient's response to medical treatment. These needs may include, but are not limited to, adjustment to illness, poor or limited coping abilities, functional impairment, mental illness, guardianship issues, compliance, need for additional resources due to limited funds available, substance abuse, cultural differences, death, dying, bereavement, and family welfare, including abuse, neglect, and domestic violence. Adoptions in the mother/ baby area. • Provides timely and effective interventions for patients and families in emergency and crisis, including referrals to appropriate support resources. • Educates team members regarding the socio-economic, emotional and cultural issues that impact care delivery, coping skills, and response to treatment. • Serves as an advocate for the patient and family. Serves as a lead resource and assists with referrals in coordinating charity and financial resources, guardianship issues, family problems or conflicts, and competency issues. • Assists with the maintenance of information and referral lists relative to post-acute care resources. • Administers and interprets tests and measures of psychosocial functioning for the purpose of diagnosing mental, emotional, behavioral, addictive, and development disorders and disabilities. • Develops and implements appropriate assessment- based treatment plan. Consults with team managers, statutory and voluntary agencies and patient’s relatives to ensure compliance with treatment plan. • Provides crisis oriented Psychotherapy and connects patient and family with the appropriate resources. • Supervises and trains lower level social workers, students or interns. • Applies specialized clinical Knowledge and advanced clinical skills in the areas of assessment, diagnosis, and treatment of mental, behavioral, addictions disorders or conditions and makes appropriate referrals or transfers to the correct level of care. Required : • One full year experience and/or internship in a medical social work role in and acute hospital setting or agency. • Experience with maternal/child populations • Licensed Social Worker (LSW) • Valid driver’s license and auto insurance with a good driving record Preferred: • Two years’ experience in an acute hospital setting • Master’s degree in social work • Minimum of 2 years of prior hospital or community-based social work experience • Licensed Clinical Social Worker (LCSW) • ACSW (Academy of Certified Social Workers) Northwestern Medicine is an equal opportunity employer (disability, VETS) and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status. Background Check Northwestern Medicine conducts a background check that includes criminal history on newly hired team members and, at times, internal transfers. If you are offered a position with us, you will be required to complete an authorization and disclosure form that gives Northwestern Medicine permission to run the background check. Results are evaluated on a case-by-case basis, and we follow all local, state, and federal laws, including the Illinois Health Care Worker Background Check Act. Artificial Intelligence Disclosure Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person. Benefits We offer a wide range of benefits that provide employees with tools and resources to improve their physical, emotional, and financial well-being while providing protection for unexpected life events. Click on or copy and paste URL to your browser to view detailed benefits information NorthwesternMedicine Career Page https://jobs.nm.org/benefits Please refer to the Benefits Eligibility by Employment Classification to determine benefits eligibility for job postings. If sign-on bonus is included in a job posting eligibility is as followed: Internal employees and rehires who left Northwestern Medicine within 1 year are not eligible for the sign-on bonus. Exception : New graduate internal employees seeking their first licensed clinical position as a Registered Nurse at NM may be eligible.