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Position Summary: 

The Medical Social Worker (MSW) II works as an integral member of the interdisciplinary care team to provide a wide range of social work and care management services to patients and their families in a home care and/or hospice setting with the goal of reducing or controlling psychosocial factors that may be impediments to patients’ treatment, recovery and achievement of health and/or end of life care goals in accordance with an appropriate plan of care.

Reports To: Clinical Manager

EDUCATION/SKILLS REQUIRED:

Education:

Master’s Degree in Social Work

Experience:

Two years of relevant experience, or a combination of education and experience from which comparable knowledge and skills were obtained. Health care experience preferred.

License Requirements:

Vermont LMSW Licensure or LICSW preferred.

General:

• Able to speak, read and write in English.
• Be honest, self-directed, possess initiative, display good judgment toward daily activities.
• Have the ability to communicate clearly and effectively both orally and in written work.
• Skilled in building rapport, supportive counseling, and conducting medical interviews.
• Be able to work cooperatively and in a productive manner with both internal and external customers.
• Maintain good standing with all required regulatory bodies and law enforcement agencies.
• Hold a valid driver’s license and have a reliable transportation, traveling is required for this position.

Knowledge and Special Skills:

• Knowledge of social work and care management standards of practice, insurance structures, Medicare and Medicaid rules and regulations, clinical practice guidelines and quality issues as related to the provision of home health or hospice care.
• Understanding of barriers and resources available for the needs of diverse populations.
• Skilled in crisis intervention in situations involving high risk of abuse, neglect, environmental stressors, suicide, guardianship/conservator issues, long term planning and unsafe home environment.
• knowledge of gaps in service delivery systems for population served.
• Facilitation skills and knowledge of team/small group principals and dynamics.
• Demonstrates strong communication (verbal & written) skills.
• Proficient in explaining medical problems and treatments in an accurate, relatable, and understandable way while identifying communication barriers to client achieving health care goals.
• Demonstrates a desire to build honest and trustworthy relationships with all individuals.
• Possess skills and knowledge to assess and provide case management services to patients and their families throughout the continuum of care. The incumbent will be able to appropriately utilize principles of human growth and development over the life span and will be able to assist patients and families in coping with illness, psychosocial challenges, loss and grief experiences from disability and terminal illness.
• Exhibits an understanding of their own culture as well as individual beliefs, identities, values and biases and how they contribute to their interpersonal style.
• Possess a working knowledge and experience in use of medical and mental health diagnoses, disabilities, and treatment procedures, including acute, chronic, and traumatic illnesses, substance abuse disorders, common medications and their effects/side effects, and medical terminology.
• Understands mandated reporting requirements for suspected abuse and neglect of vulnerable adults and children.
• In addition, Hospice SW will perform admissions for hospice, may supervise the day-to-day tasks of other members of the interdisciplinary team, and provide bereavement support in accordance with the hospice conditions of participation.

PERFORMANCE REQUIREMENTS:

Performance Standards:

• Provides services in alignment with patient centered/family centered best practices to include taking issues such as readiness, literacy, health literacy and cultural factors into account to ensure that education is provided to the patient and/or family to enhance their understanding and ability to manage their care.
• Conduct comprehensive initial in-home psychosocial assessments of patients’ circumstances, problems and needs related to their illnesses and assess the patient’s psychological and emotional adjustment to illness within the context of medical diagnosis, prognosis, treatment options, and psychological development. Assess psychological and social barriers to participation in treatment.
• Ensure the relevant information and data including a medical and psychosocial history; response to illness; health behavior; belief/value/cultural system; financial situation; environment; developmental level; functional status; legal history/current legal issues; and current medical status and level of care is included and documented as part of the assessment.
• Utilize assessment in facilitating the patient’s maximum use of treatment for attainment of the highest level of independence that is possible and practicable by documenting skilled service needs, treatment planning, crisis intervention, and counseling within scope of professional expertise and competence. 
• Manages a home visiting caseload of diverse patients with complex care needs: admitting clients to MSW skilled services, scheduling visits, identifying health care and community resources and services to meet patient needs and work in collaboration with the patient, caregiver, family members, and multidisciplinary care teams to develop a plan of care and goals relevant to patients defined medical needs.
• Provide care coordination in conjunction with the interdisciplinary team as well as external
• Coordinates and may lead patient care conferences, establishes goals and anticipated outcomes in alignment with the care plans.
• Maintains knowledge of regulatory and legal requirements, including but not limited to HIPPA, Medicaid, and Medicare Conditions of Participation
• organizations, government agencies, treating physicians or health care providers frequently with a strong emphasis on general education regarding the special characteristics and needs of patients dealing with illness, disabilities, palliative and end of life care in a home care or hospice setting.
• Develop and maintain knowledge and engagement with community partners and resources throughout the care and services provided.
• Facilitate and/or participate in multidisciplinary care conferences, rounds or family meetings as appropriate.
• Document assessments, care plans, and interventions per documentation guidelines and policy. File mandated reports within the State of VT regulations and law.
• Apply expertise, knowledge, and process in assessing, planning, intervening, monitoring and evaluation of clients and patients.
• Assess, identify, and recommend interventions based on patient/family resources and obstacles for complex psychosocial and medical situations.
• Collaborate as a member of the interdisciplinary team and utilize skill and expertise in facilitating appropriate care for patients, caregivers, and families, assessing and intervening on behalf of patients and families and making referrals for consultation and services.
• Supports the progression of care, against established care guidelines, protocols and assessing and intervening where appropriate.
• Under the clinical supervision of MSW III or MSW Lead, triage and coordinate care for complex medical and psychosocial issues
• Consult with social work lead, senior staff, director, and/or supervisors to exchange information, coordinate care, consult on cases, and as needed for unusual situations that require more intervention.
• Attend required meetings, collaborations, or specific sessions to assist in updating policies and/or procedures or quality improvement activities.
• Accurate and timely completion of all required clinical and administrative documentation within established regulations or requirements.
• Facilitate a respectful and collaborative environment regarding conflict and change responses.
• Any other related duties as so designated by manager.

Professional Accountability: 

• Adheres to the University of Vermont Health Network Code of Conduct in all aspects.
• Conducts oneself in a safe manner by adhering to all safety practices, rules, policies, and standards which govern the agency.
• Meet requirements of position with regards to schedule, time off, attendance, and accuracy of reporting
• Monitor and focus on own learning requirements with continued education and growth. Complete competencies to maintain any licensure.

WORKING CONDITIONS:

Traveling is required May work in community based settings, and clients’ homes and outdoors May work during non-business hours May experience:

• Hostile and emotionally upset clients, family members, visitors and staff
• Stress due to a demanding profession
• An exposure to blood-borne pathogens

• A variety of environmental exposures such as inclement weather, animals, firearms, tobacco use, dust, and other client based activities and preferences

ESSENTIAL PHYSICAL REQUIREMENTS:

Must walk, sit, stand, bend, lift and move intermittently during working hours Must have the ability to push, pull and lift from the floor, up to a total of 50 pounds and be able to move with the weight, as to organization’s standards Climbing-be able to navigate stairs of varying heights and degrees Balancing-be able to maintain balance Kneeling, crouching, stooping, twisting, reaching below waist level, reaching overhead and reaching torso level Manual finger dexterity-will need dexterity to perform duties and use equipment Visual acuity-will need sufficient eyesight to drive a car, use office equipment and perform duties Auditory acuity- will need to assist individuals in person and by telephone