Summary The Social Worker in Home Health assists patients and families in coping with problems resulting from severe or long-term illness, and with difficulties in recovery and rehabilitation. The Social Worker is responsible to assist patients with community resource planning for identified long term care needs, assist patients with obtaining information regarding advance directives, and update case records. Responsibilities Assists the patient, significant others, physician, and health care team staff to understand significant personal, emotional, environmental, and social factors and difficulties related to the patient's health problems; which interfere with maximizing the benefit of medical services and the plan of care. Contributes as a health care team member to the development of comprehensive, integrated treatment plans for patients. Instructs health care team members on community resources available to assist patients. Plans for continuity of care with hospitals and community agencies. Determines patient’s ability to cope with daily living problems and assists patient in coping with illness. Assists the patient and significant others to understand, accept, follow, and implement medical recommendations. Assists the patient and significant others in utilizing community resources which will help the patient to achieve and maintain optimal functioning. Identifies gaps in community resources and stimulates resource development and/or improvement. Visits patient according to Plan of Treatment; completes a progress note for each visit; and submits progress notes to the agency on an at least weekly basis. Participates in staff conferences and committees as necessary. Fulfills necessary mandatory education on annual basis Provides in-service to agency staff as needed Sends the physician a written summary report on patient's condition at least every 60 days All other duties as assigned Education and Experience Education & Experience Master's Degree from a school of Social work accredited by the Council of Social Work Educations. One year of social work experience in a health care setting. License Requirements Current CPR certification Current Driver's License, vehicle insurance, and access to a dependable vehicle or public transportation Additional State Specific Requirements AL, AR, CO, DE, GA, ID, IL, IN, KY, LA, MA, MD, MI, MN, MS, NJ, NM, NV, OH, OR, SC, TX, WI,WV: Licensed as a Social Worker from the State Board of Social Work.