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Fallon Health Social Worker-Growing Elder Service Plan - Amherst NY in Amherst, NY, New York


About Fallon Health Weinberg - PACE:

Fallon Health Weinberg-PACE is a long-term care program for older adults who need a nursing-home level of care , but wish to stay living at home and in their community. We are a Program of All-inclusive Care for the Elderly (PACE), providing complete medical care and support services so you or your loved one can remain living safely at home .

All care is coordinated and provided by an interdisciplinary team specializing in geriatric care, who work with participants and their caregivers to create an individualized care plan .

Brief Summary of Purpose:

The employee in this position is responsible for

  • Providing the Fallon Health Weinberg PACE participants and families with psychosocial assessments and interventions related to the maintenance of the Partripant(s) in the community.

  • Within an interdisciplinary team (IDT) care setting, promotes and maintain the mental and social health of enrolled participants through assessment, treatment, teaching and counseling. Provides basis casework and consultation for Fallon Health Weinberg PACE participants. Facilitates communication between participants, their family and the IDT. Facilitates the participant counsel to create a dialogue among participants, caregivers and the staff. Responsible for the implementation of social work care plan and coordination of social work with other services


Work is performed under the general supervision of the day center manager. The employee interacts with staff and managers on a frequent basis and has access to confidential information as necessary to perform job duties. Therefore the employee is expected to respect the right to privacy and security of PHI (Protected health Information) and EPHI (Electronic Protected Health Information). Positive and effective interpersonal/communication skills are required and are a high propriety in this position.

  • Conducts initial and periodic assessments (minimally every 6 months). Participates in developmental in the development of the plan of care. Assessments and plan of care must be completed prior to scheduled team meeting

  • Ensures communication of participant changes to team members

  • Monitors and coordinated the advance directives with participant/family and primary care

  • Assess the participant, family and home environment for the need for social work planning and intervention. Determines participant and family needs related to social supports, financial support, assists with setup of money management systems as needed, counseling, housing appropriateness and psychological supports

  • Provides ongoing therapy with participants related to disabilities, role reversals in family and transition of lifestyles due to changes in independence

  • Coordinates with mental health-related providers, including drug and alcohol treatment, to arrange appointments and share pertinent information

  • Provides individual and family counseling, develops and leads group counseling and activities

  • Confers with the participants and family regarding individual expectations and long and short term goals

  • Coordination of 24 hour care delivery

  • Conducts family support groups,. Education or training sessions and routine family/caregiver meetings for education , support and dialogue

  • Assists with reviewing Medicaid eligibility, monitors time frame for recertification and facilitates Medicaid applications for certification and recertification

  • Assists the Participant or family in making necessary applications for public assistance, housing, placement, etc

  • May participate in intra-inter-department meetings and intra-agency meetings, conferences and seminars, as required

  • Maintains current knowledge of community resources and new regulations regarding eligibility for community assistance

  • Consults with and advises staff members as to the relationship of social, emotional and cultural factors to health and medical care, and as to the availability of social services in the community

  • Maintains necessary record keeping functions pertaining to participants’ care and progress and completes documentation requirement in the medical records

  • Maintains quality documentation of therapy and counseling provided

  • Participants in discharge planning in the event of disenrollment

  • Participates in team meetings as scheduled

  • Participates in program and policy development of social work component

  • Supervises the work of student social work interns

  • Participates in department’s quality improvement activities and monthly reporting. Is a member of the Quality Management Committee

  • Able to constantly work with people from various socio-cultural backgrounds in an effective manor

  • Able to frequently accept and utilize supervision

  • Able to constantly work independently

  • Able to constantly communicate and listen effectively in a team setting and individually

  • Able to respond to individuals’ spoken needs constantly

  • Able to read, and understand/interpret a variety of correspondence, written materials, data and polices and procedures constantly

  • Able to retrieve and distribute printed material

  • Able to comprehend oral instructions and remember the same in detail on a consistent basis

  • Able to proofread typed material for contextual, grammatical, typographic or spelling errors, on a frequent basis

  • Able to cope with and work on a fast paced (frequent)and sometimes high stress (occasionally) work environment



High School diploma required

Master’s degree in social work from an accredited college required

New York State license to practice as a social worker preferred


Active, unrestricted license as a Social worker in New York state; current Driver’s license


  • Two years’ experience working in a health related area required

  • Minimum of 1 year of experience working with a frail or elderly population required

  • Only act within the scope of his or her authority to practice. Meet standardized set of competencies for the specific position description established by Fallon Health Weinberg PACE and approved by CMS before working independently.


Job ID 5667

# Positions 1

Category Social Work