The provision of critical services and social casework to a caseload of patients with alzheimer’s and dementia related diseases and their caregivers, in accordance with the standards of the social work profession, agency policies, and requirements of the project partner and funding source, the Montefiore Health System (MHS) Center for Excellence for Alzheimer’s Disease (CEAD) :
Play a key role on the CEAD care team working with healthcare providers, alzheimer’s patients and their caregivers and partner agencies
Implement comprehensive care plans that include caregiver needs and appropriate referrals to community-based and government support services. This will include making referrals to such organizations and agencies identified in the care plan, making periodic follow-up calls with the designated organization or agency and with the patient/caregiver dyad; accepting and responding to email messages or phone calls from the dyad; and entering all contacts in the Montefiore electronic medical record system and CEAD databases required for reporting to the State Department of Health.
The provision of In-Office Assessment of the social and emotional needs of the older adult client and caregivers, utilizing prescribed standardized assessment instruments; securing where appropriate the assistance of other social work and/or other professional consultants.
The development and implementation of a written case plan for the provision of the full range of social services for the older adult client(s) and family, including:
Individual and family counseling and guidance in the resolution of problems of the client(s) and family.
The provision of specific information about health, welfare, education and recreation services available to serve the older client.
Screening of client eligibility, and application for such benefits and entitlements as may be available and helpful.
The arrangement for direct provision of services such as homemaker, home health aide, public assistance, Medicare, Medicaid, emergency cash relief, legal aid, protective services, vocational placement, medical and psychiatric examination and therapy, housing, etc.
Referral to, and maintenance of cooperative relationships with other community agencies, to meet the needs of clients.
Ongoing meetings and calls with clients to evaluate client functioning, monitor risk, assess the status of current services, and update and revise the case plan; seeking appropriate guidance from the care team in situations requiring clarification and consultation.
Actively participates in cross-discipline team meetings with healthcare providers
Represents and interprets the agency at community conferences and meetings.
Participates in training and unit meetings.
Completes required case records, reports and statistics within mandated timeframes, utilizing computers
Performs such other duties as assigned.