Responsibilities:
The Social Worker plans, organizes and implements social work services to participants and their caregivers in accordance with InnovAge policies and all applicable regulations. Conducts psychosocial assessments, participates in care planning and acts as a liaison between the participant and the interdisciplinary team.

Assessment and Care Planning

• Performs initial assessments of participants to obtain a psychosocial history including cognitive status, mental health and substance use history, behavioral concerns, family dynamics, and current social supports.
• Participates within the interdisciplinary team in the formulation of Plans of Care for InnovAge program participants, as well as in other interdisciplinary team settings that plan, coordinate and monitor the care of InnovAge program participants.
• Conducts in-person reassessments of enrolled participants every six months or as determined by policy and best practice. Assessments include collaboration with caregivers and assessment of housing risk.
• Completes home visits at least annually and as needed to work proactively with participant, IDT, and community partners to maintain the participant’s functioning as independently as possible in their community.

Case Management

• Develops a collaborative relationships with internal and external partners. Utilizes a solution-oriented perspective to facilitate resolution of participant needs.
• Acts as a primary liaison between the participant/family and the IDT to facilitate communication.
• Facilitates, mediates and documents participant care conferences, family meetings and facility partnership meetings.
• Actively and assertively manages respite and hospital length of stay (applicable for non-Pennsylvania locations). Collaborates with participants, caregivers, facilities and the IDT to ensure clear communication regarding participant status and plan.
• Works in collaboration with hospital discharge planners, primary care, IDT, families and caregivers regarding participant’s disposition from the hospital. Partners with the InnovAge Mental Health Team when hospitalization is psychiatric.
• Provides referrals to and coordinates assessments with contracted facilities. Supports the participants in the tour and move planning process as clinically indicated.
• Completes Pre-Admission Screen and Resident Review (PASSR) for all nursing home admissions from the community.
• Partners with the InnovAge Medicaid Department to assist the participant in keeping resources within the guidelines of Medicaid eligibility and supports the recertification process.
• Advises the participant or financially responsible party about housing co-pays and for non-Pennsylvania locations, may be responsible for notifying the Medicaid department of the need to generate a Supportive Housing Form.
• Actively participates in the completion of ROIs, ULTC 100.2s and other paperwork needed to provide care (applicable for non-Pennsylvania locations).
• Supports the inter-center transfer process for participants who move between catchment areas, relaying participant history and care plan issues to the receiving social worker.
• Provides referral support to community resources and participates in inter-agency coordination of care.
• Proactively supports the participant grievance process, involving the Center Director in all potential voluntary disenrollments due to dissatisfaction.
• Assists participants who are disenrolling with transition to outside services, including timely referral back to the single entry point and completion of disenrollment paperwork.
• Maintains accurate and timely documentation and paperwork including participants’ electronic medical records according to policies and procedures.
• Attends and actively participates in IDT meetings, Social Services department meetings, Cross Sites and Annual Competencies.
• Provides on-call support after hours as assigned, if applicable.

Psychosocial Support

• Monitors changes in the patient’s condition and needs.
• Assists physician, or intermediate care provider, and other team members in understanding the significant social and emotional factors related to the health problems.
• Provides psychosocial services in accordance with established standards.
• Evaluates quality of psychosocial services provided and adjusts interventions as clinically indicated.
• Schedules home visits as necessary according to patient needs.
• Acts as a resource to other team members and staff regarding topics such as dementia, difficult behaviors, and difficult personalities. Supports the IDT in establishing behavior management plans.
• Strive for continuous growth and development of Cultural Competency exhibiting an understanding, awareness, and respect for diversity.
• Provides caseload coverage support as assigned for MSW PTO, open FTEs, and general team needs.
• Performs other duties as assigned.

Please refer the Job description for details