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Social Worker-Field

Company: Aspire Health
Location: Detroit
Posted on: November 11, 2018

Job Description:

Aspire Health is the nation's largest community-based palliative care provider. Aspire specializes in providing an extra layer of support to patients facing a serious illness through an ambitious palliative care program focused on caring for patients in their homes and outpatient clinics.-- Aspire's clinicians are experts in providing patients with relief from the symptoms, pain, and stress of a serious illness; helping patients and caregivers navigate the healthcare system; guiding patients and caregivers through difficult and complex treatment choices; and providing emotional and spiritual support to patients and their families.
The Aspire Health Social Worker is responsible for providing supportive and medical social services to patients and their families in the home. This will include a range of tasks such as directly providing support to Aspire's patients and families in the home as well as coordinating patient transition from facility to the home. The Aspire Social Worker assists the medical team in completing a comprehensive psycho--social assessment and subsequently establishing a patient's plan of care in alignment with the care team. The Social Worker would establish and advocate for support services to patients and families, as well as care plans that are sensitive to the patient's unique psychosocial needs, health status, and overall goals and values. Responsibilities will be highly varied, and appropriate candidates will be multitalented, flexible problem solvers who are eager to tackle complex problems and tasks.
Ideal candidates will have experience identifying and coordinating the needs of chronically ill patients and families as well as supporting clinicians to help them operate as efficiently as possible.

- Regular attendance is an essential function of the job
- Prior healthcare experience serving chronically ill patients living with limited resources, and/or mental illness preferred
- Health plan, home health, or hospice experience a plus
- Telephonic case management or care coordination experience preferred
- Strong customer service orientation
- Patient, compassionate, and professional demeanor required
- Exceptional organizational skills and ability to multi--task
- Self-starter with an entrepreneurial spirit and demonstrated problem solving skills
- Strong writing, Word, Excel, and database management skills
- Extremely strong work ethic
- Experience working in a fast-growing, rapidly changing environment
- Must have reliable automobile, valid driver's license and minimum state required liability auto insurance; Social Workers travel in personal vehicle with reimbursement for mileage
- Bilingual is a plus--
- Master's degree in social work and licensure at that level required
- Minimum of 3 years social work experience required, preferably in a centralized care management team environment

- Provide in home and telephonic psychosocial assessment and supportive services to patients and families as part of an interdisciplinary team. Care coordination with the patient, family, caregivers, and other providers includes:
- Supporting hospice consultation and transition
- Goals of care discussions and education on treatment plan recommendations at end of life
- Social support and transportation needs
- Financial counseling
- Identifying non--clinical community resources
- Mitigating family dynamics and patient compliance issues
- Assess, identify, and close clinical and non--clinical gaps in patient care
- Appropriate triage and escalation of routine, urgent and emergent patient calls
- Document social work assessments, care plans, and interventions
- Collaboration with field based NPs/PAs and physicians to develop and implement effective treatment plans and interventions for complex patient care issue
- Identifying community resources and assisting Aspire's patients and families in accessing those resources
- Referral to Aspire Health chaplain resources when appropriate
- Provide grief support and reassurance to patients and family members
- Participation in weekly interdisciplinary team meetings
- Perform miscellaneous job-related duties as assigned

Keywords: Aspire Health, Detroit , Social Worker-Field, Healthcare , Detroit, Michigan

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