GAP Care Solutions is a comprehensive, personalized healthcare planning and coordination company. GAP provides full social work case management throughout the continuum of care, and specializes in transitional care, palliative care and placement services.
The GAP Social Worker is a member of a multidisciplinary team whose primary function is to introduce and explain GAP services to patients in hospitals, Skilled Nursing facilities and home settings. In addition, the MSW helps develop appropriate goals to reduce risks and improve outcomes related to the patient's health and well being.
The MSW seeks to develop a relationship with the health care facility, patient and family system so that the case management needed to improve overall outcomes in regards to health care can be carried out effectively and efficiently.
- Provides initial and ongoing psychosocial assessments and counseling to patient and family system.
- Conducts ongoing risk assessments and education around patient risks and ways to improve safety.
- Participates in discharge planning meetings and/or plan of care meetings with referral sources or other health care/community organizations.
- Develops appropriate plan of care goals, objectives and interventions in cooperation of patient/family system.
- Coordinates plan of care with referral sources and other internal and external health care services.
- Provides ongoing education to patient /family system regarding health care service options.
- Makes appropriate referrals as developed in the plan of care.
- Assists in developing and maintaining relations between Centrix Health Resources and outside medical/health care services.
- Maintains appropriate and timely documentation in patient chart.
- Participates in training and in-service education for Centrix Health Resources and outside health care services / community organizations.
- Customer Service attitude and professional behavior in dealing with both internal and external customers.
- Critical thinking skills.
- Knowledge of community resources or ability to learn.
- Knowledge and understanding of psycho-social processes related to illness and/or decline and ability to put theory into clinical practice in daily work with patients and family system.
- Good listening skills, communication skills and follow through.
- Business development awareness and mindset.
- Enthusiasm and passion for service to others.
- Ability to be flexible in daily schedule within defined work hours.
- Able to serve diverse populations in their homes.
- Case management and time management skills.
- Masters of Social Work required from a school accredited by the Council on Social Work Education.
- At least two years social service experience in a health care setting.
- Experience as a medical social worker with elderly and/or terminally ill and their families preferred.
- Hospice experience a plus.
Reports directly to GAP Care Solutions Administrator.