The Social Work Case Manager is a core member of the intensive in-home case management services offered by the Home Health program. Under the direction of the Home Health Administrator, the Social Work Case Manager works collaboratively with an RN Case Manager partner providing the psychosocial case management focus to a caseload of up to 22 clients in order to maintain quality healthcare across the service continuum, decrease fragmentation of care, assist the client to remain engaged in HIV care and treatment, maximize health outcomes, reduce HIV transmission, and remain independent in their home or community-based setting.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Receive inquiries regarding participation in the Home Health Program; explain conditions of participation and obtain informed consent from clients to participate in the Home Health Program.
Collaborate with the Nurse Case Manager to assess whether the client is eligible for either the Home-Based Case Management Program or Medi-Cal Waiver program via intake interviews including obtaining historical and current psychosocial information. Consult with the Nurse Case Manager in setting the client’s Cognitive Functional Assessment score.
Perform initial comprehensive psychosocial assessment and ongoing reassessments, including an assessment of the client’s psychosocial, legal, financial, social support system and medical status. Document the results of the assessments in the prescribed format.
Develop the initial service plan in collaboration with the Nurse Case Manager. Facilitate involvement of the client or client’s legal representative or family in the development and revisions of the service plan.
Participate fully in case management activities within his/her area of expertise, and in collaboration with the assigned Nurse Case Manager.
Document results of the intake and subsequent contacts on the computer and in written form.
Consult with the client’s attending physician, primary care practitioner and/or other medical providers as needed to coordinate treatment plans and advocate for the client as necessary.
Identify those services available to the client and coordinate services and/or make appropriate referrals as required in the service plan.
Document services needed but not available at APLA and refer to other community based organizations.
Monitor the service plan regularly, at least every 60-90 days with the Nurse Case Manager. Document the service plan review per protocols.
Negotiate with subcontracted psychotherapy service providers when services have either not been provided as requested, or have been inadequately provided.
Maintain timely and appropriate contact (as specified in the Joint AIDS Case Management Protocols/County Contracts) with assigned clients. Clients are to be seen minimally every 90 days for face-to-face reassessment, and have contact beyond that as indicated.
Identify and follow up on instances of abuse, neglect, and exploitation that bring harm or create the potential for harm to clients.
Adhere to all applicable professional, legal, and ethical standards of clinical practice in the provision of services, including but not limited to: mandated reporting, provision of effective services, case documentation, client confidentiality/HIPAA regulations, ensuring client safety, and maintaining professional boundaries.
Establish working relationships with members of the client's social support systems (e.g. significant others, family members, friends, conservators, etc.). Provide emotional and practical assistance to help them in maintaining their support to the client.
Promote understanding of the psychosocial factors impacting persons living with HIV disease or AIDS.
Attend case conferences and interdisciplinary treatment team meetings, present reports and collaborate with other team members, document the outcome of the team decisions in the client's chart.
Obtain training annually on topics that address HIV/AIDS, case management, psychosocial needs, and co-morbid disorders.
Document all actions made on a case in the specific client record in accordance with protocols.
Accurately complete all documents in a timely manner.
Attend unit, division, and other agency meetings as assigned.
OTHER DUTIES MAY BE ASSIGNED TO MEET BUSINESS NEEDS.
Training and Experience:
Masters degree in social work, counseling, or clinical psychology. License as an LCSW, LMFT, or Psychologist preferred, but registered interns will be considered. Two years’ experience providing social work or mental health services to HIV-infected/affected populations.
Psychosocial assessment; case management practices; HIV/AIDS, public benefits, community resources, substance abuse, psychiatric illness, home health care procedures, health care reimbursement mechanisms. Microsoft Office suite including Word and Excel.
Assess biopsychosocial needs, utilize community resources, communicate effectively, participate as an effective member of an interdisciplinary team; conduct sensitive, empathetic interviews; respect the dignity of clients who may have experienced stigma or discrimination; prepare accurate, concise, comprehensive reports; maintain confidentiality of the clients being served; maintain client records in an accurate and timely manner. Demonstrate proficiency with both verbal and written skills. Meet reasonable deadlines.
WORKING CONDITIONS/PHYSICAL REQUIREMENTS:
This is primarily a field position that requires only occasional bending, reaching, stooping, lifting and moving of office materials weighing 25 pounds or less. The position requires daily use of a personal computer and requires entering, viewing, and revising text and graphics on the computer terminal and on paper. The position requires use of a personal vehicle; up to 50% of the time position will involve driving throughout Los Angeles County, getting into and out of one’s vehicle and meeting with clients in their homes. Some stair climbing and walking uphill is required in getting from one’s vehicle to some clients’ homes. The initial work schedule is a 2-day 10 hour workweek, but final work schedule will be agreed upon by case management team, with Program Manger’s approval. There is no evening, weekend, holiday, or after-hours on-call work required.
Must possess a valid California driver’s license; proof of auto liability insurance; and have the use of a personal vehicle for work related purposes.
APLA Health’s mission is to achieve health care equity and promote well-being for the LGBT and other underserved communities and people living with and affected by HIV. We are a nonprofit, federally qualified health center serving more than 14,000 people annually. We provide 20 different services from 15 locations throughout Los Angeles County, including: medical, dental, and behavioral health care; PrEP counseling and management; health education and HIV prevention; and STD screening and treatment. For people living with HIV, we offer housing support; benefits counseling; home health care; and the Vance North Necessities of Life Program food pantries; among several other critically needed services. Additionally, we are leaders in advocating for policy and legislation that positively impacts the LGBT and HIV communities, provide capacity-building assistance to health departments across the country, and conduct community-based research on issues affecting the communities we serve. For more information, please visit us at aplahealth.org.
A dynamic, diverse staff, a team oriented, collaborative environment, an excellent benefits package, competitive salaries, exciting advancement opportunities, and extensive professional development.