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POSITION SUMMARY: The Social Worker is responsible for planning, organizing and implementing social work services to Rocky Mountain Health Care Services (RMHCS) program participants and families. The Social Worker is an essential member of the interdisciplinary team (IDT) and vital to the integration of person-centered care.

MISSION: Improving lives, Optimizing wellness, Promoting independence

RESPONSIBILITIES AND DUTIES:

ESSENTIAL JOB FUNCTIONS:

• Responsible for all initial, 6 months, change of condition and annual assessments. Meets all assessment deadlines of assessment completion.
• Presents assessments and overview of participant at care plan conferences with the goal of providing a foundation for development of the Plan of Care and team discussion of participant issues.
• Acts as liaison with participant and caregivers regarding orientation to and ongoing relations with interdisciplinary team, day center, and other RMHCS staff, including volunteers.
• Provides ongoing support and education to participants and family regarding a variety of issues, including but not limited to the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics and changing roles. Performs home visits as needed to assess living environment, mistreatment, and support system.
• When needed, facilitates in home meetings with participant and family members assisting in creating a healing environment and client centered plan of care for participant.
• Provides referrals to contracted facilities, behavioral health, community agencies and organizations.
• Assist participant in making housing choices. Will proactively work to partner with participant and/or caregivers to advocate participant in maintaining appropriate housing and assist participant to function at most independent community level possible. Coordinates as needed hospital discharges in communication with attending medical and multi discipline RMHCS team members.
• Initiates referrals to external resources with community agencies such as Adult Protective Services, Housing Authority, and/or Colorado Springs Police Department
• Facilitates meetings with family, caregivers, participant and team update or problem solves issues regarding the Plan of Care. Mediates discussions between all parties. Refers potential voluntary and involuntary dis-enrollment letters to Executive Director for signature. Completes voluntary and involuntary dis-enrollment packets, forwarding them to Social Work-CM Manager for a scheduled 1on1 review meeting.
• Actively partners with IDT for end of life issues. Works to provide emotional support, education, and funeral/financial planning referral. Facilitates referrals to provider for palliative care, or nursing home placement as appropriate. Assists participants and caregivers to complete MDPOA, Proxy, and DNR directives as needed. Provide supervision to student interns in MSW internship collaborations between their respective universities and RMHCS. Assist in training of new Social Workers-Cm by providing shadowing experiences and information that is team specific.
• Attends and actively participates in a variety of organizational meetings related to participant care or daily operations, including but not limited to: daily IDT Meeting, Quality Assurance Committee, and various in-services. Acts as a back up to the Social Work Manager for the interdisciplinary team (IDT) meetings, as needed.
• Maintains appropriate documentation in participants medical records including assessments, change of status; temporary or permanent placements; hospital discharges; participant staffings; home visits; disenrollments and other significant events.
• Other duties as assigned.