Carolina Meadows is looking for an experienced Social Worker that has a strong interest in working with older adults at our Continuing Care Retirement Community!
This position is primarily responsible for the care coordination and psychosocial support of Carolina Meadows residents in the Health Center. The Social Worker acts as an advocate, resource, educator, facilitator, counselor, historian and organizer for residents and their families. The Social Worker evaluates residents’ mental, emotional, and psychosocial needs to understand how these needs connect with the residents’ overall health and wellbeing. The Social Worker facilitates care coordination and solution-focused supports to promote resident dignity and optimal benefit within the long-term care continuum.
Essential Functions:
Resident Assessment
Builds relationships and rapport with residents and family members. Establishes trust as the foundation of the professional relationship and maintains ongoing communication regarding resident needs as relevant to the resident’s wellbeing.
Conducts psychosocial assessments at regular intervals for ongoing determination of resident needs.
Provides psychoeduction and counseling to residents and family members regarding resident conditions, needs and welfare.
Documents resident assessments and encounters in an accurate and timely manner.
Resident Care Coordination
Promotes resident dignity, autonomy, and individual rights in a holistic approach throughout the care continuum.
Attends the Health Center’s morning Interdisciplinary Team meeting.
Assists with signing in and orienting new residents.
Completes all admissions paperwork with resident or responsible party within 48 business hours of admission. Provides resident with admissions packet. Ensures that required information and insurance cards are properly filed and updated in the Electronic Health Record. Reviews advanced directives and makes sure these are on file.
Assists with resident orientation to the Health Center and reviews all services available, such as dietary, rehabilitation, behavioral health, and other ancillary services.
Facilitates Early Advantage admission agreement for Health Center admissions in collaboration with the Marketing Team.
Completes psychosocial assessments and develops a person-centered Care Plan for psychosocial well-being as required at specific intervals, including but not limited to within 5-7 days of admission and on a quarterly basis. Conducts relevant cognitive and mental health assessments in collaboration with the Interdisciplinary Team.
Accurately documents resident visits, assessments, care plans, and other social work interventions within the Electronic Health Record.
Collaborates with the Interdisciplinary Team for resident care planning and participates in resident care plan meetings as scheduled.
Provides education, support, and facilitation of end-of-life care.
Serves as the liaison between the resident and family and any relevant ancillary services to ensure quality continuity of care.
Arranges and facilitates discharge planning when it is determined by the IDT that a resident is ready to discharge to a lower level of care. Communicates between residents, family members, and Carolina Meadows to advocate for appropriate resident supports and care transitions.
Coordinates appropriate referrals upon discharge, such as to home care, home health, hospice/palliative care, medical providers, etc.
Ensures provision of recommended Durable Medical Equipment
Confirms medication and prescription needs are met
Provides psychoeducation and resources regarding resident’s continued care needs
Coordinates transportation services upon resident’s discharge
Submits and monitors the We Care Connect survey once the resident discharges
Receives, manages, documents, and ensures proper and timely follow-up of grievances.
Participates in QAPI meetings, providing information relevant to resident care, mood, and behavior.
Manages internal resident room change processes and notifies the Health Center’s IDT when a resident becomes permanent to the facility.
Facilitates move-out process with a resident’s family/Responsible Party upon their death. Coordinates facility’s sympathy card signing and mailing.
Acts as a liaison between the Health Center and the consulting services in conjunction with the IDT
Assists with initiating Long-term Care Insurance claims and submit monthly LTC Insurance continued care forms.
Attends the Pines’ quarterly Family Night events
Resident-Focused Support and Problem Solving
Monitors residents for needs related to life transitions and adjustments.
Attends Interdisciplinary Team meetings to address person-centered approaches to resident needs, such as weekly PAR meetings and The Fairways morning meetings.
Provides psychosocial support, counseling, and psychoeducation to resident and family members related to residents’ diagnoses, treatment plans, and overall welfare.
Integrates Social Work values, ethics, and best practices into approaches to resident care.
Facilitates informational groups or psychotherapeutic support groups for residents experiencing stress, adjustments, grief, or other identified areas of concern.
Assists residents and family members with accessing available supports within the Carolina Meadows community. Provides information about referrals to medical, community, financial, and other relevant resources available.
Personal and Professional Development
Participates in staff development and training opportunities that promote professional growth and the ability to remain knowledgeable about best practices in Social Work.
Establishes and nurtures a professional network within the Carolina Meadows organization and with community partners.
Maintains detailed and accurate documentation of work efforts, policies and procedures, and work performance as required to demonstrate measurable goals of resident support.
Additional Duties as Assigned.
The ideal candidate for this position would possess the following:
A Master’s Degree in Social Work or an equivalent degree in a related field. A Bachelor’s of Social Work degree would be considered if a candidate has strong experience in the field.
A minimum of two years’ experience working in a long-term care or health care setting with the provision of care coordination or case management services. Experience working in a Skilled Nursing Facility setting is preferred.
An interest and ability to work with older adults in a Continuing Care Retirement Community.
Aptitude to effectively collaborate with an Interdisciplinary Team of professionals.
Ability to work in a fluid environment with evolving demands.
Strong interpersonal skills, demonstrating discretion, empathy, and patience.
Robust written and verbal communication skills.
Strong organization and creative problem-solving skills. Must be self-motivated.
Proficient in MS Office Suite and the use of Electronic Medical Records.
