Medical Social Worker

KeyPerformance Area

1.     Assessment and Care Planning:

·       Conduct psychosocial assessments of residents upon admission and on anongoing basis to identify their needs, strengths, and preferences.

·       Develop individualised care plans in collaboration with residents,families, and interdisciplinary teams to address social, emotional, andfinancial concerns.

·       Provide ongoing case management services, including monitoring progress,advocating for residents' rights, and coordinating services with externalagencies.

2.     Counselling and Support:

·       Offer emotional support and counselling to residents and their familiesto help them cope with the challenges of aging, illness, and transitions.

·       Facilitate support groups and therapeutic interventions to address issuessuch as grief, depression, and adjustment to long-term care.

·       Provide crisis intervention and conflict resolution as needed to promotea supportive and harmonious living environment.

3.     ResourceReferral and Advocacy:

·       Identify and connect residents with community resources and services,such as financial assistance, home care, and legal aid, to enhance theirwell-being and independence.

·       Advocate for residents' rights and access to services within the nursinghome and the broader community, ensuring their voices are heard and their needsare met.

·       Collaborate with government agencies, healthcare providers, and communityorganizations to optimise support networks for residents and families.

4.     Discharge Planning and Transition Support:

·       Coordinate discharge planning processes to ensure smooth transitions forresidents returning home or transferring to other care settings.

·       Assess residents' support systems and environmental factors to determineappropriateness of discharge plans.

·       Provide referrals and linkages to community resources, including homehealth services, transportation, and social support networks.

5.     Educationand Training:

·       Conduct educational sessions and workshops for residents, families, andstaff on topics related to aging, caregiving, mental health, and advance careplanning.

·       Provide training and support to interdisciplinary team members on socialwork principles, communication strategies, and best practices for addressingpsychosocial issues.

6.     Documentation and Reporting:

·       Maintain accurate and confidential records of assessments, interventions,and progress notes in compliance with regulatory standards and organizationalpolicies.

·       Generate reports and statistics to track outcomes, trends, and areas forimprovement in social work services.

Participate in caseconferences, team meetings, and quality improvement initiatives to ensureholistic care and continuous enhancement of services.