Social Worker- PACE

TriHealth is actively recruiting for a Social Worker to work with the PACE of Cincinnati PACE Center located in Norwood Ohio. Program of All-Inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility.

Job Overview:

The PACE Social Worker (MSW) is a member of the PACE Interdisciplinary Team (IDT) and is responsible for completing comprehensive initial social work assessments for new PACE participants and social work reassessments for existing PACE participants as part of the PACE IDT care planning process. The PACE Social Worker (MSW) provides direct social work and care management services to PACE participants in concert with the PACE IDT and current care plan. These services include participant social work screenings, case management coordination, counseling services, and referrals to community agencies as appropriate. The PACE Social Worker (MSW) is responsible for being knowledgeable regarding local community resources and services available to participants and caregivers. The PACE Social Worker (MSW) educates participants, caregivers, and PACE staff on psychosocial factors and participant/caregiver dynamics impacting participant care.

Job Requirements:

Master's Degree in Social Work from an accredited college or university. (Required)
2 - 3 years experience in a health-related area. (Preferred)

Job Responsibilities:

Participates as a PACE Interdisciplinary Team (IDT) member and is responsible for completing a comprehensive initial social work assessment for new PACE participants and social work reassessments on existing PACE participants as part of the PACE IDT care planning process. 
In collaboration with the IDT, develops care plans for social work and delivers social work interventions to participants identifying and considering the medical, physical, social, and emotional needs of PACE participants. 
Maintains responsibility for the psychosocial well-being of participants through the coordination of 24-hour care delivery working in concert with the IDT. Identifies, provides, and coordinates participants' medically related social, psychological, and spiritual needs. Implements social work interventions, case management, individual and caregiver counseling, and comprehensive psychosocial support. 
Consults with and advises PACE staff members on the relationship of social, emotional, and cultural factors impacting access to health, medical care, and community resources. 
In concert with the IDT, refers participants and families to appropriate community resources, acts as a liaison with such organizations, and serves as a care advocate for PACE participants at all times. 
Monitors PACE participants for changes in their health and psychosocial status that require a social work reassessment. Promptly communicates pertinent changes in participant status to the IDT. Provides ongoing support and education to participants and caregivers regarding the aging process, dementia management, grief and loss, end-of-life considerations, disease processes, family dynamics, and the PACE service delivery model. 
Completes and maintains social work documentation in the PACE EHR in accordance with the federal PACE regulation and organizational policy. Attends IDT and morning meetings and reports on participants’ social status. Maintains knowledge of Medicaid financial eligibility criteria, including documentation to be completed. Maintains knowledge of participant liability and applicable share of cost. Maintains knowledge of applicable state nursing home Level of Care requirements. Supports the PACE QI program and participates in PACE QI activities as assigned. 

Working Conditions:

Bending - Occasionally 
Climbing - Occasionally 
Concentrating - Consistently 
Continuous Learning - Consistently 
Hearing: Conversation - Consistently 
Hearing: Other Sounds - Frequently 
Interpersonal Communication - Consistently 
Kneeling - Rarely 
Lifting <10 Lbs. - Occasionally
Pulling - Occasionally 
Pushing - Occasionally 
Reaching - Frequently 
Reading - Consistently 
Sitting - Frequently 
Standing - Frequently 
Stooping - Rarely 
Talking - Consistently 
Thinking/Reasoning - Consistently 
Use of Hands - Frequently 
Color Vision - Occasionally 
Visual Acuity: Far - Frequently 
Visual Acuity: Near - Frequently 
Walking - Consistently

TriHealth SERVE Standards and ALWAYS Behaviors

At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following:

Serve: ALWAYS... 
• Welcome everyone by making eye contact, greeting with a smile, and saying "hello" 
• Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist 
• Refrain from using cell phones for personal reasons in public spaces or patient care areas

Excel: ALWAYS... 
• Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met 
• Offer patients and guests priority when waiting (lines, elevators) 
• Work on improving quality, safety, and service

Respect: ALWAYS... 
• Respect cultural and spiritual differences and honor individual preferences. 
• Respect everyone's opinion and contribution, regardless of title/role. 
• Speak positively about my team members and other departments in front of patients and guests.

Value: ALWAYS... 
• Value the time of others by striving to be on time, prepared and actively participating. 
• Pick up trash, ensuring the physical environment is clean and safe. 
• Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.

Engage: ALWAYS... 
• Acknowledge wins and frequently thank team members and others for contributions. 
• Show courtesy and compassion with customers, team members and the community