Work where every moment matters. Every day, almost 30,000 Hartford HealthCare employees 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 (MSW). 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. Our Social Workers (MSW) utilize their extensive education and training to provide personalized care to our patients in a rewarding environment that promotes autonomy. The Home Care Social Worker (LMSW) is a Master’s prepared, Licensed Clinician who will engage patients, in their home, to determine their short and long-term needs, and will provide short-term counseling/interventions to meet care plan objectives. The Home Care Social Worker will collaborate with patients, their families, physicians, and home care team to identify and address patient’s bio-psychosocial needs, barriers to care, risk-factors, etc. The Home Care Social Worker is familiar working with patients who have complex health care and psychosocial problems that require a high degree of clinical oversight and creative problem solving. The Home Care Social Worker works independently and uses critical thinking skills to make accurate, and at times, quick judgments, and has the ability to respond appropriately to crisis situations. JOB RESPONSIBILITIES Key areas of responsibility Collaborates with the interdisciplinary team regarding patients that were identified for Social Work Services, and through IDT/case communication, assists with identifying patients that would benefit from Social Work Services. Completes comprehensive in-home psychosocial evaluations. Evaluations include: Consideration of developmental, social and/or cultural, substance abuse, psychological, environmental, and medical issues Physical, social, emotional, and familial characteristics Use of evidence-based assessment tools to determine cognitive status and behavioral health needs including Dementia, Depression, Anxiety, etc. Home safety, family dynamics, caregiver strain, and other risk factors including suicide Patient/family understanding of their disease treatment options Strengths, available supports, and barriers to care Determine appropriate level of care including needs for long/short-term skilled-nursing facilities, assisted living facilities, adult day care, etc. Based on a comprehensive, culturally competent assessment collaborates with the patient and family to create a care plan with measureable goals. Implements short-term interventions to address identified barriers and promote health and well-being. Provides clinical treatment services in form of triage, crisis intervention, individual or family therapy, screening and planning Utilize Motivational Interviewing and Coaching skills to assist patients/families in identifying and addressing goals. Using identified strengths, encourage self-determination and independence Act as educators for patients, families, the community, and other professionals regarding disease prevention, disease progression, impact of illness, health maintenance, and adherence to treatment regimens Advocate for the needs and interests of patients to improve access to care and improved delivery of services Provide ongoing assessment of patient and family needs. Monitor and alter care plan goals and interventions as necessary Maintains timely documentation of social work services, which reflect the patient and client systems’ pertinent information for assessment and treatment; social work involvement and outcomes. Facilitates team based care and collaboration Work collaboratively with primary care and specialty physicians and other members of the health care team to improve quality of life Functions as an integral member of the multidisciplinary team. Participates in case conferences and IDT meetings Assists the health care team in understanding social/psychological factors related to patient’s care Acts as a consultant for Agency staff regarding abuse, neglect, exploitation, and community resources Identify HHC and community-based resources for patients and families as appropriate In addition, the position involves other duties such as: Participates in Agency staff meetings and appropriate interdisciplinary meetings Conducts outreach activities for purposes of program marketing, community education, and collaboration with other service providers Act as liaison to other community services and agencies Participates in health care programs as required Participates in appropriate external and internal professional activities Participates in educational activities regarding area of expertise Follows Agency procedures in delivering casework services Maintains productivity standard Experience 2-3 years health care experience, inclusive of acute and community health experience Licensure, Certification, Registration-LMSW required Knowledge, Skills and Ability Requirements Considerable knowledge of social, cultural, economic, political, religious, medical, psychological and legal issues which influence the behaviors of patients and families. Familiarity with various evidence-based assessment tools: PHQ-9/PHQ-2, SLUMS, BIMS, FAST, SAD Caregiver Strain Index, etc. Knowledge of and ability to obtain community resources (town/state/federal programs and eligibility requirements) Proven ability to work effectively independently and in a team environment. Must be flexible with ambiguity and change processes. Excellent written and verbal communication skills. Strong organization skills and attention to detail. Strong computer skills including Microsoft Office, Epic experience a plus New clinicians will be required to complete: Mental Health First Aid Certification QPR Training Movement Disorder Training 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 employees-- we provide a competitive benefits program designed to ensure work/life balance. Every moment matters. And this is your moment Job: Professional Clinical* *Organization: Hartford HealthCare at Home *Title: *Social Worker (LMSW) - HomeCare Location: Connecticut-Bridgeport-765 Fairfield Ave Bridgeport (10411) Requisition ID: 24151348