PACE Social Worker - Upham's PACE

The PACE Social Worker serves as a core member of the PACE Interdisciplinary Team (IDT) through the provision of therapeutic interventions, case management, and advocacy on behalf of program participants and their caregivers.

Duties & Responsibilities:

• Provide care to a caseload of older adults and their families/caregivers in a variety of settings including, the PACE Day Health Center, participant’s homes, and care facilities.
• Provide in-person, telephonic, and virtual supportive counseling to participants, families, and caregivers.
• Conduct initial, bi-annual, and unscheduled comprehensive assessments of participants.
• Develop and implement fluid, participant centered care plans.
• Collaborate with the Community Resource Specialist to support participants and caregivers in completing their case management needs.
• Work closely with the Behavioral Health Therapist and Chaplain to ensure that participant’s mental and spiritual wellness are supported.
• Attend daily meetings with the PACE IDT
• Contribute to the problem-solving process of participant care issues using social work values and principles.
• Act as liaison between the IDT and caregivers/family.
• Orient participants, families, and caregivers to PACE services.
• Coordinate care with outside providers and programs.
• Play an active role in the end-of-life transition for participants, families, and caregivers. Identify, organize, and implement support groups for participants and caregivers.
• Complete documentation in accordance with Upham’s PACE and CMS standards.
• Supervise Social Work Interns as needed.
• Present ethical dilemmas at quarterly Ethics Committee meetings.
• Perform other duties as required by the position and/or as assigned by the Manager of Social Work.