Housecall Providers https://www.housecallproviders.org/ Housecall Providers is a Portland area nonprofit organization and one of the largest providers of medical care exclusively in the home in the Western United States. We are proving every day that in home medical services for homebound and chronically ill patients can improve health outcomes, increase patient comfort, reduce health care costs and increase provider satisfaction. We are a proud part of the CareOregon family of health organizations. Our Mission Improving lives by bringing health care home. Our Vision To sustainably transform home-based medicine so all homebound adults and those living with serious illness have access to care that improves their quality of life. Our Values Compassion and respect, authentic relationships, collaboration, courage, social justice. Diversity Statement We embrace the diversity of our employees, patients, and those who care for them. Through awareness and advocacy, we are working to create health equity by recognizing and reducing barriers that affect non-dominant groups within Housecall Providers and our communities at large. The quadruple aim is real at Housecall Providers In home medical care for homebound patients is proven to increase patient comfort, improve health outcomes, reduce health care costs and increase provider/care team satisfaction. Housecall Providers has saved Medicare millions of dollars, while providing better care to our patients, ensuring greater patient comfort, improved health outcomes and care team satisfaction. With the population aging, more people are suffering from multiple chronic conditions and degenerative diseases. This trend will continue as roughly 10,000 baby boomers a day enter the Medicare system. If you receive an offer of employment for this position, it is contingent on the satisfactory completion of a pre-employment background check, immunization review, and drug screen (including THC/Marijuana). CareOregon is a federal contractor and must comply with all federal laws. Job Title Social Worker Department Advanced Illness Care Exemption Status Non-Exempt Requisition # 24627 Direct Reports N/A Manager Title Advanced Illness Care Manager Pay & Benefits Estimated hiring range $79,430 - $97,080, 5% bonus target, full benefits. www.careoregon.org/about-us/careers/benefits Posting Notes This community-based position has the opportunity to move to a 4/10 schedule after training. The training schedule will be M-F, standard business hours. Job Summary The Social Worker is responsible for delivery of social work services to patients, including psychosocial evaluations, ongoing counseling, casework services, coordination of referrals, transitions, and potentially palliative care and bereavement services. These patients may have advanced illnesses and often have other complex medical/psychosocial/addiction issues. The Social Worker provides support and care for patients in various settings including: all types of patients’ home settings, assisted living residences, shelters, hospitals, emergency departments, skilled nursing facilities, clinics, and specialty settings. Essential Responsibilities + + + Conducts comprehensive psychosocial assessments and makes appropriate referrals to community resources as well as provides education to patients and families regarding community resources, benefits and entitlements. + Collaborates with clinical and support staff regarding patient/family/caregiver issues. + Conducts patient and family counseling and education considering family system/dynamics and coping methods to all age groups and makes appropriate referrals to other community resources if indicated. + Help patient and family/caregiver develop coping strategies to manage declining physical health, and emotional or spiritual needs. + Closely partners with patient providers and interdisciplinary care team across the continuum to facilitate care that meets the individual’s personal needs, values, and preferences. + Provides short term crisis intervention and assumes active role of advocate for family. + Assists clinicians and clinical teams with management of transitions of care when patients are moving from one setting to another, including (but not limited to) from place of residence to hospital or nursing home and back, assisting with placement as needed. + Provides direct patient care support in a variety of settings. For those working closely with advanced illness patients, the Social Worker utilizes palliative care principles, trauma informed care, motivational interviewing and case management strategies. + Participates as a member of interdisciplinary care team assisting with establishing and implementation of psychosocial care plan in patients with serious, complex and/or chronic illness which could include partnering with Primary Care, Hospice or AIC team members. + Assists patients and family with advance care planning which includes discussions about goals of care/treatment, answering general questions about power-of-attorney documentation, the POLST form and the Oregon Advanced Healthcare Directive Form. + Communicate and coordinate with other providers to ensure care is coordinated and consistent with patient’s goals of care, including AD/POLST. + Assists with establishment of POA-HC (power of attorney for health care) and with establishment of end-of-life care plans as needed. + Provides education to patients, family members, caregivers and Housecall Providers’ staff regarding mental health issues, grief, resiliency, hospice services, community resources, benefits and entitlements. + Provides consultation on ethical issues that arise for HCP staff. + Conducts mental status exams (e.g., MMSE, SLUMS, MoCa) as requested by Providers. + Provides advocacy for patients and families with various community agencies, care facilities and other institutions as needed. + Assists clinicians with organization and/or facilitation of care conferences for assessment, education or conflict management. Organizational Responsibilities + Perform work in alignment with the organization’s mission, vision and values. + Support the organization’s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals. + Strive to meet annual business goals in support of the organization’s strategic goals. + Adhere to the organization’s policies, procedures and other relevant compliance needs. + Perform other duties as needed. Experience and/or Education Required + Master’s degree in social work from an accredited college + Current Oregon LCSW, LMSW or CSWA license + Minimum 1 year work experience in geriatrics, home health, hospice, hospital, primary care/specialty care clinic or other community based mental health or outreach social work + Valid driver’s license, acceptable driving record, and automobile liability coverage or access to an insured vehicle + CPR certification at hire or within 6 months in position Preferred + Experience dealing with substance use disorders, care coordination and needs assessment for high- risk populations Knowledge, Skills and Abilities Required Skills and Abilities + Practice within the scope of license where applicable, and as required by law and regulation. + Ability to assess psychosocial needs, establish and implement a social work plan of care, triage urgent and crisis situations, and stay focused + Ability to be sympathetic to a patient, family or caregivers needs, and be able to deal with people in various states of pain, trauma and tragedy + For those working with advanced illness patients, employees must feel comfortable supporting patients at the end of their life; including facilitating, evaluating and coaching advanced care planning conversations performed by AIC Team or other CO programs + Ability to exercise sound clinical judgment, independent analysis, critical thinking skills and knowledge of medical and behavioral health conditions when identifying clients’ multidisciplinary needs, developing health goals and communicating with providers + Must be a clear, timely and compassionate communicator and be able to maintain healthy boundaries + Ability in case management and counseling with frail and complex patients + Ability to communicate effectively with diverse staff and patients, their families and caregivers + Able to establish therapeutic relationships with patients, families, caregivers and staff using effective communication + Excellent interpersonal skills + Ability to adhere to organizational standards, policies and procedures + Ability to work both independently and collaboratively + Ability to work under pressure to meet deadlines + Ability to take initiative and utilize innovative techniques and ingenuity + Ability to interact with various departments throughout the organization + Ability to work flexible hours, if needed + Must be organized and have the ability to plan, prioritize and coordinate multiple projects or tasks + Must have general computer skills and a working knowledge of Electronic Medical Records systems, MS office, Outlook, and the internet + Ability to work in an environment with diverse individuals and groups + Ability to learn, focus, understand, and evaluate information and determine appropriate actions + Ability to accept direction and feedback, as well as tolerate and manage stress + Ability to see, read, hear, and speak clearly for at least 6 hours/day + Ability push, pull, stand, sit, and perform repetitive finger and wrist movement to for at least 3-6 hours/day + Ability to lift, carry, pinch small objects, walk, bend, and climb stairs for up to 3 hours/day + Ability to operate a motor vehicle in all kinds of weather conditions Working Conditions Work Environment(s): ☒ Indoor/Office ☒ Community ☐ Facilities/Security ☐ Outdoor Exposure Member/Patient Facing: ☐ No ☒ Telephonic ☒ In Person Hazards: May include, but not limited to, physical and ergonomic hazards. Equipment: General office equipment Travel: Requires travel outside of the workplace at least weekly; the employee’s personal vehicle may be used. Driving infractions will be monitored in accordance with organizational policy. Schedule: This position may occasionally require more than 8 hours per day. Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment. Veterans are strongly encouraged to apply. We are an equal opportunity employer. CareOregon considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, or veteran status. Visa sponsorship is not available at this time.