Job Description

Location Detail: 227 Dunham St Norwich (10414)

Work where every moment matters.

Every day, over 40,000 Hartford HealthCare colleagues come to work with one thing in common: Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticut’s most comprehensive healthcare network as a Social Worker. 

Hartford HealthCare at Home, the largest provider of homecare services in Connecticut, has been fulfilling our mission for more than 115 years. Our Person-Centered Care Model allows our employees to learn and grow within our organization, all while providing integrated support to the patient. As part of Hartford HealthCare, we leverage cutting edge technology to provide quality care in our client’s home. Most importantly, our employees are appreciated for the real differences they make in both the lives of their clients and their clients’ families.

The Home Care Social Worker (MSW/LMSW) is a Master's-prepared, licensed or license-eligible clinician who engages patients in their homes to determine their short- and long-term needs and provides short-term interventions to help meet patients' goals of care.

The Home Care Social Worker collaborates with patients, their families, physicians, and the home care team to identify and address patients' biopsychosocial needs, barriers to care, risk factors, and other challenges. This role requires experience working with patients who have complex healthcare and psychosocial needs.

The Home Care Social Worker works independently, uses critical thinking skills to make accurate and, at times, quick clinical judgments, and responds appropriately to crisis situations.

Job Responsibilities

Comprehensive Assessment

• Completes comprehensive in-home psychosocial evaluations. Evaluations include:
  • Consideration of developmental, social, cultural, substance abuse, psychological, environmental, and medical factors.
  • Assessment of physical, social, emotional, and family characteristics.
  • Use of evidence-based assessment tools to determine cognitive status and behavioral health needs, including dementia, depression, anxiety, and related conditions.
  • Evaluation of home safety, family dynamics, caregiver strain, and other risk factors, including suicide risk and access to basic needs.
  • Assessment of the patient and family's understanding of disease processes and treatment options.
  • Identification of strengths, available supports, and barriers to care.
  • Determination of the appropriate level of care, including long- and short-term skilled nursing facilities, assisted living facilities, adult day care programs, and other services.

Care Planning & Clinical Intervention

• Collaborates with the interdisciplinary team regarding patients identified for Social Work Services and assists in identifying additional patients who may benefit from social work support through IDT and case communication.
• Based on a comprehensive, culturally competent assessment, collaborates with patients and families to develop a care plan with measurable goals.
• Implements short-term interventions to address identified barriers and promote health and well-being.
• Provides clinical treatment services in the form of triage, crisis intervention, individual and family therapy, screening, and care planning.
• Utilizes Motivational Interviewing and coaching techniques to assist patients and families in identifying and achieving goals.
• Encourages self-determination and independence by building upon identified strengths.

Patient, Family & Community Education

• In collaboration with the multidisciplinary team, serves as an educator for patients, families, the community, and other professionals regarding:
  • Disease prevention
  • Disease progression
  • The impact of illness
  • Health maintenance
  • Adherence to treatment regimens
  • Accessing short- and long-term community resources

Advocacy & Resource Coordination

• Advocates for the needs and interests of patients to improve access to care and enhance service delivery.
• Provides patients and families with resources to support discharge planning and transitions of care.
• Maintains timely documentation of social work services that accurately reflects assessment findings, treatment interventions, patient and family needs, social work involvement, and outcomes.

Team-Based Care & Collaboration

• Works collaboratively with primary care and specialty physicians, as well as other members of the healthcare team, to improve quality of life and support patients' goals of care.
• Functions as an integral member of the multidisciplinary team.
• Participates in case conferences and interdisciplinary team (IDT) meetings.
• Assists the healthcare team in understanding social and psychological factors related to patient care.
• Acts as a consultant to Agency staff regarding abuse, neglect, exploitation, and community resources.
• Identifies Hartford HealthCare at Home and community-based resources appropriate for patients and families.
• Performs other duties as assigned.

Qualifications

Requirements & Specifications

Education

• Master's Degree in Social Work.

Experience

• 1-2 years of clinical experience required.
• Experience in a healthcare setting is strongly preferred.

Licensure, Certification & Registration

• LMSW or LCSW required.
• Licensure required within one year of hire.

Language Skills

• Bilingual English/Spanish preferred.

Knowledge, Skills & Abilities

• Considerable knowledge of social, cultural, economic, political, religious, medical, psychological, and legal issues that influence the behaviors of patients and families.
• Familiarity with evidence-based assessment tools, including:
  • PHQ-9 / PHQ-2
  • SLUMS
  • BIMS
  • FAST
  • C-SSRS
  • Caregiver Strain Index
• Knowledge of and ability to obtain community resources, including town, state, and federal programs and eligibility requirements.
• Proven ability to work effectively both independently and as part of a team.
• Ability to adapt to ambiguity and changing processes.
• Excellent written and verbal communication skills.
• Strong organizational skills and attention to detail.
• Strong computer proficiency, including Microsoft Office; Epic experience is a plus.

We take great care of careers

With locations around the state, Hartford HealthCare offers exciting opportunities for career development and growth. Here, you are part of an organization on the cutting edge – helping to bring new technologies, breakthrough treatments and community education to countless men, women and children. We know that a thriving organization starts with thriving colleagues-- we provide a competitive benefits program designed to ensure work/life balance. Every moment matters. And this is your moment

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