provide in-home services to our patients.

• Evaluates and develops a plan of care personalized to fit the patient’s emotional and social needs;
• Assesses the patient’s social and emotional state as it relates to his/her illness or injury, needs for care and his/her response to treatment and adjustments to care;
• Assesses any relationships of the patient’s medical and nursing/therapy needs in the home setting, financial resources and available community resources;
• Provides appropriate action/intervention to obtain available community resources to assist in resolving issues that may be impeding the patient’s recovery;
• Instructs patients and families in treating and coping with social and emotional responses;
• Provides ongoing assessment of patient and family needs and responses to teaching;
• Observes, documents and reports changes in the patient’s condition and response to interventions/treatment to the interdisciplinary care team and Clinical Manager;
• Participates in the discharge planning process;
• Participates as a member of the interdisciplinary care team in care coordination activities and acts as a resource to other health team members in the identification and resolution of patient needs;
• Able to supervise/instruct the performance of the Social Work Assistant (BSW/LSW) to assure that all medical social services are provided to patients in compliance with company, government and professional standards as applicable;
• Maintains and submits documentation timely per company policy including any case conferences, patient/physician community contacts, visit reports progress notes.