Position Description
The Medical Social Worker (MSW) is a qualified professional who, in accordance with the plan of treatment, assists the physician and other team members in understanding the significant social and emotional factors related to the health problems. The MSW also participates in the development of the plan of treatment, prepares clinical and progress notes, works with the family, utilizes appropriate community resources, participates in discharge planning and in-service programs and acts as a consultant to other agency personnel.
Essential Duties and Responsibilities
* Provides medical social work services where appropriate, to individuals and families receiving skilled services from the Agency
* Resolves social or emotional problems that are or are expected to be an impediment to the effective treatment of the patients medical condition or rate of recovery
* Develops and implements a plan of care that necessitates the skills of a qualified medical social worker to be performed safely and effectively
* Assesses the relationship of the patients medical and nursing requirements to the patients home situation, financial resources and availability of community resources
* Takes appropriate action to obtain available community resources to assist in resolving the patients problem
* Provides counseling services that are required by the patient
* Provides medical social services to the patients family member or caregiver on a short term basis (i.e. 2-3 visits) when the HHA can demonstrate that a brief intervention by a medical social worker is necessary to remove a clear and direct impediment to the effective treatment of the patients medical condition
* Completes evaluation paperwork and patient care plan submitted to Clinical Supervisor per agency policy and procedure
* Provides medical social services including assessment, evaluation, procedures, teaching, and training activities as outlined in the patient Plan of Care
* Submits completed visit notes; communication notes per agency policy and procedure
* Submits change orders per agency policy
* Maintains open lines of communication to all members of the continuum of care team
* Acts as a preceptor in the orientation of new medical social work staff as requested
* Attends staff meetings, team conferences, and educational in-services per agency requirements
* Participates in Process Improvement (PI) program by assisting with collection of data and serves on PI team upon request
* Participates in discharge planning process in accordance with Medicare Criteria and agency policy and procedure
* Follows agency policies and procedures
* Performs these and all other duties as assigned by the Administrator
* Able to lift 40 pounds from floor to shoulder
* Repetitive walking, standing, sitting, bending, and use of hands
* Able to drive a car 2-4 hours per day
REQUIRED Knowledge, Skills, and Experience
* A Master's Degree (MSW) from a school of Social Work accredited by the Council on Social Work Education or Bachelor degree (BSW)
* Current unencumbered State professional license
* One (1) year of social work experience in a health care setting
* An automobile to be used for work, current drivers license, good driving record and proof of insurance
* Proficiency in clinical skills
* The ability to make sound professional clinical judgment
* The ability to assess and document patient needs and formulate individualized patient care plans to meet those needs
* Excellent verbal and written communication
* Proficiency in personal computer use including email, clinical, word processing, and spreadsheet software
Houston, TX
Founded 25 years ago,Visiting Physicians Association (VPA) is the nation’s leader in house call medicine. We specialize in caring for patients with complex health issues.
With our advanced medical technology, we are able to provide comprehensive care for every patient all within the comfort and privacy of their home. Our model ensures that patients medical needs are addressed in a timely manner.
We prioritize and are committed to best practices and high quality outcomes for our patients.
VPA is part of U.S. Medical Management (USMM). USMM is a family of companies that provides home-based medical services for elderly and other adult patients with complex health issues.
Our Experience
Expertise in geriatric care
Experience with Accountable Care Organizations (ACO) and value-based healthcare initiatives
Pioneer ACO (2012-2014)
CMS Independence at Home Program (2012 - current)
MSSP ACO (2015 to current)- 2016 Results
Experience with clinically integrated networks, population health management, and value-based initiatives
Fully implemented compliance, quality management and infection control programs
Patient specific proprietary clinical protocol software for chronic care management
Overview
Established in 1993
Largest physician house call practice in the U.S.
Over 200 full time Primary Care Providers (Physicians, NP's, PA's)
Physician-led model
Serve over 50,000 unique patients annually
Leader in government shared savings programs
Robust technology infrastructure
State of the art laboratory, mobile x-ray, ultrasound in the home
Member of the American Academy of Home Care Medicine (AAHCM)