Position Summary: The Social Worker assesses and supports the psychosocial well-being of elders upon admission, at discharge, and during daily life at St. John’s. This valuable hybrid role supports 11 Rehabilitation residents with 41 Long Term Care bed unit. This team member ensures the interdisciplinary team honors resident rights and facilitates appropriate placement supports in the community. Upon admission and throughout the course of the resident's stay, coordinates the interdisciplinary team to ensure goal alignment and individual planning for each resident’s specific needs. This role requires a commitment to innovative solutions, elder-directed goal setting, and frequent family support.  

Qualifications & Education Required: Minimally a Bachelor’s degree in Social Work or related field, MSW preferred. Minimum one year of experience in a health care setting, with knowledge of Rehabilitation care, insurance coverage, discharge planning and end-of-life care. 

Core Organizational Competencies:

• St. John’s Brand Characteristics - Embrace living by being Friendly, Respectful, Responsive, Compassionate, Innovative and Fun towards elders, families, and colleagues. 
• Teamwork - Actively participates. Assists team members; offers encouragement. Acknowledges/welcomes elders. Keeps team members informed. Recognizes achievements and efforts of others. 
• Job Knowledge - Consistently demonstrates working knowledge of all aspects of the job. Remains current on job-related changes and trends. 
• Planning/Organization - Demonstrates initiative; plans appropriately. Uses time, materials, and resources effectively. Organizes work to ensure commitment and priorities. 
• Productivity - Consistently maintains high activity and efficiently produces an acceptable volume of work. Consistently meets deadlines and commitments. 
• Quality - Consistently produces accurate, timely work which meets required quality standards. Pays attention to detail. Sets high standards of performance for self and actively seeks continuous improvement. Provides elder-driven care. 
• Reliability - Consistently delivers on commitments. Can be counted on to accomplish tasks without follow-up. Available when required by elder or team and can be counted on to help or assist when needed. Responds on time. 
• Demeanor (attitude) - Embraces change with optimism. Addresses concerns appropriately. Positively communicates. Good listener. Consistently maintains a positive demeanor. 

Position Responsibilities: 

• Assess and support well-being in admission, discharge, and during daily life at St. John’s.  
• Performs casework counseling services for elders and family members/responsible parties in specifically assigned areas, being mindful of the need to advocate for resident rights and wishes.
• Continual assessment and documentation of elders’ needs, which include evaluation for depression, changes in mental status, anxiety, family dynamics/crises, and interpersonal interactions with family, staff and other elders.
• Assist with discharge planning, transfers, and transitions by arranging for appropriate community services and completion of all corresponding paperwork.
• Completes appropriate referrals for Hospice, CHE Psychological Services, Elderplan etc.  
• Assumes responsibilities for designated committees or projects of the department or facility as requested.
• Oversees creation of meaningful elder experience through facilitating communication between staff, elders and families.
• Assist with the admission process through supportive contacts as elders adjust to the new environment, complete initial assessments and complete all corresponding admission paperwork.
• Completes corresponding paperwork for hospital transfers and internal moves within the community.
• Assure that documentation is in accordance with facility and regulatory agency guidelines.
• Actively participates in care rounds weekly and communicates ongoing changes.
• Provides emotional support to elders and families in time of grief.
• Completes grievance forms and communicates with the care team regarding concerns and complaints voiced by residents and family.
• Facilitates conferences – discharge planning, initial, annual and significant change family meetings and any care team conferences.
• Creates and regularly updates comprehensive care plan, in addition to completing routine MDS assessments.

Physical Requirements: 

• Frequent moving and lifting, pushing, pulling and bending. Frequently squatting and occasionally reaching.
• Exposure to Conditions – May be exposed to infectious diseases and physical aggression.