Social Worker

On Lok PACE

We are a non-profit committed to our participants.

Dedicated to The Care of Elders:

PACE (Program of All-Inclusive Care for the Elderly) was developed to answer the many problems around caring for frail seniors.

The PACE model is centered on the belief that it is better for the well-being of seniors with chronic care needs and their families to be served in their community whenever possible.

Seniors, their family members, and caregivers face many issues, including transportation to appointments, management of medications, coordination of medical care from different specialists, lack of social interaction, and ability to stay alone at home.

On Lok PACE participants receive in home care services and transportation to a On Lok PACE center for primary medical care, social and recreational activities, and other senior care services.

We understand the importance of a system that works together.

Your expertise, drive and passion can help us carry out our mission to improve lives and advance healthcare.

Join our team of leaders to begin a rewarding career!

POSITION SUMMARY:

The Social Worker provides direct case management services to On Lok participants.

The primary role of the MSW is to assist participants and their family/caregivers to cope with the social and emotional issues and practical arrangements related to maintaining their independence.

With support from the Social Work Lead, the MSW serves as an integral member of the Interdisciplinary team (IDT) providing assessments, coordination, treatment planning, information and referral to community resources and other social work services to meet the complex needs of participants and their families.

DUTIES / RESPONSIBILITIES:

Clinical Practices and Case Management
1.

Utilize independent judgement and discretion to provide case management to a panel of participants.
2.

Conduct initial and routine psychosocial assessments on new and existing participants in order to develop, implement and update individualized care plans and interventions.
3.

Partner with caregivers and support system to develop care plan and deliver services.
4.

Identify risks and other psychosocial problems.
5.

Identify service needs of each participant; advocate, refer, coordinate and follow up in a timely fashion.
6.

Provide individual counseling.
7.

Facilitate family conferences.
8.

Reach out to the larger community to meet participants' specific needs.
9.

Assess needs and complete discharge planning when a participant dis-enrolls from On Lok.
10.

Facilitate participant and/or caregiver groups and participate in special events such as weekend caregiver workshops.

Interdisciplinary Team Member Roles and Responsibilities
1.

Act as the main liaison between participants, caregivers, the team, and the community.
2.

Work with relevant departments such as Health Plan and other community agencies (e.g.

RCFE, NF, DAAS)
3.

Adhere to all ethical and legal standar...