MSW/LCSW PACE

NeighborHealth PACE Social WorkerJoin NeighborHealth's Neighborhood PACE program, where the PACE Social Worker plays an active, engaging role in a model of care designed to help older adults live safely in their communities. As part of a dynamic Interdisciplinary Team (IDT), you will develop individualized plans of care and support participants both at the PACE Center and in their homes. You will address a wide range of needs—including high risk mental health, end of life planning, support with medical decision making, and caregiver support—while conducting psychosocial assessments, creating treatment plans, providing counseling, and collaborating with IDT members, with opportunities to run groups. Candidates must hold an MSW, be passionate about serving adults 55+, and possess or be working toward LCSW or LICSW licensure in Massachusetts; experience with older adults is preferred. The successful candidate will be able to perform the following responsibilities: Provide clinical social work and case management services for Neighborhood PACE participants. Conduct clinical assessments; develop, implement, and update treatment plans within the care plan; and coordinate interventions with providers and the Interdisciplinary Team (IDT) in accordance with Neighborhood PACE policies and procedures. Complete intake assessments, including comprehensive psychosocial assessments, and identify factors affecting each participant's current level of functioning. Complete initial assessments and contribute to the plan of care by identifying how PACE services can maintain or improve participant well-being and community functioning. Provide caregiver support and facilitate or coordinate family meetings, as appropriate. Participate actively on the IDT by presenting initial and biannual assessments; documenting and following up on care plan interventions; and partnering with participants to identify goals of care. Develop and lead clinically informed activities (e.g., group counseling, psychotherapy, end-of-life support, resource coordination, intern supervision, or ethics/complex case consultation). Pursue continuing education and apply learning to practice. Facilitate hospital, rehabilitation and skilled nursing facility (SNF) admissions, discharges, and care transitions, as determined by the (IDT), including coordination for participants requiring psychiatric hospitalization. Serves the role of participant and family advocate by clarifying and representing the participant's voice and perspective to the team and other community providers. Maintains professional, accurate and timely social service documentation in the participants' medical record. Provides timely communication to appropriate staff regarding the following (disenrollment, conversion to long term care, transfer of sites participant and/or caregiver demographic changes) Reports allegations of abuse to appropriate state agency; provides support and resources to participant as he/ she will accept; completes required documentation. Performs other duties as required. Frequent local travel.