Performs in home health patient assessments, care plan formulation and direct short term interventions that aid the patient and family in meeting health related needs in the home setting. Responsible for the most complex cases. Completes duties in an effective and timely manner in collaboration with the home health care team and community resources.

Provides social work services to individuals or groups including: screening, psychosocial assessment, discharge planning, determination of social work goals, appropriate concrete and/or therapeutic interventions and follow-up. Exercises a substantial degree of professional judgment, recognizing deviations from the usual patient/family functioning, anticipating problems and taking measures to maximize coping capabilities.

Conducts initial assessment and establishes a plan of care through psychosocial, financial, functional, and environmental data; establishes and follows a plan of care, which identifies problems and evaluates outcomes. Provides ongoing assessment of patient/family needs and applies appropriate interventions. Updates and revises plan of care as indicated.

Plans for discharge from medical social services according to organization standards and utilizes internal systems and community resources to assure patient/family needs are being met.

Implements interventions substantiated by assessment as appropriate to the needs of the patient/client system and consistent with available resources. Initiates and coordinates interventions with the activities of other members of the health care team. Collaborates with community agencies and institutions to plan continued care and to coordinate interventions related to finances, housing, childcare, family discord and other psychosocial problems. Provides crisis intervention services.

Documents activity according to department and program protocols or standards. Maintains and updates patient records according to organization, state, and federal guidelines.

Assists with managing utilization of resources especially as related to patients with complex continuity of care needs.

Provides education to patients/families regarding Advance Directives for health care decision-making. Assists with execution of these documents as appropriate.

Communicates effectively with patients, family, other members of the health care team and community agencies and facilities resolution of issues which could impact on continuity of care (e.g., prior-approvals, application requirements, transfer paperwork). Communicates with physician, care coordinator, other team members to collaborate and update plan of care. Provides support to patient's family members in the case of a patient's death.

Establishes effective professional relationships, positively representing the social work profession throughout the organization and in the community. Promotes constructive approach to problem solving. Adheres to the professions Code of Ethics; consistently practices within a framework guided by ethical principles.

Licenses & Certifications

Social Worker license issued by the state of Wisconsin, and

A valid drivers license issued by the Division of Motor Vehicles.

Degrees

Master's Degree in Social Work.

Required Functional Experience

Typically requires 2 years of experience in social work that includes experiences in a home care or hospice environment.  Will consider New Grad applicants.  

Knowledge, Skills & Abilities

May be required (based on work location) to have a current driver's license granted by the state of residency with a driving record that meets Aurora fleet safety standards and proof of automobile liability insurance. Must possess exceptional assessment skills. Demonstrates exceptional understanding of family dynamics and psychosocial issues related to disability, acute and chronic illness and problems associated with advanced age. Ability to provide short-term counseling to patients and their families. Exceptional collaboration skills, advocacy abilities and ability to perform as a team player. Exceptional knowledge of community resources and effective in accessing these resources. Must possess above average time management skills to comply with productivity standards, patient needs, regulatory requirements and communication needs. Intermediate computer skills including word processing, presentation applications and electronic mail.

Ability to prioritize and be flexible in your daily schedule to need unexpected patient/family needs

Team player, works well with interdisciplinary team members 

Self Motivated, able to work independently and with the team

Positive attitude, accepting change

Excellent communication skills. 

Salaried full-time

Position provides social work to hospice/palliative patients in the Burlington/Walworth County market. 

Position is based in the community with travel between homes every day. Approximately 30-90 miles per day.  

Typical hours are Monday-Friday 8:00a-430p.  9 days per pay period Rotation of on call  1 day per week until 8pm and 1-2 weekends per month 8a-8p.  Holiday rotation is approximately 1 holiday per year 8a-8p. 

Will provide full time training for at least 12 weeks

Salaried position with additional shift pay when working on call (hourly rate in for hours worked on call)