Provides services and/or establishes standards addressing the social and/or emotional factors that impact the clients ability to achieve the goals of the Plan of Care.

Services are provided under the direction of a physician and in conjunction with other health care team members in accordance with the established policies and practices of the Agency.

ESSENTIAL FUNCTIONS/AREAS OF ACCOUNTABILITY

1. Assesses the psychosocial status of clients to determine factors that may interfere with client’s ability to achieve goals.
   • Completes assessments in a timely manner and in accordance with Agency policy.
   • Develops a written plan to provide information and direction to other health team members.
   • Documents all findings, plans, interventions, and client progress in the clinical record.
   • Communicates plans and changes to the physician and/or nursing supervisor and other Agency staff through the care plan, written progress notes, and participation in care conferences.
   • Initiates referrals as appropriate
2. Prepares social histories to augment existing service, or as a guide in determining or changing level of service. This may include cultural factors, financial concerns and support system.
3. Demonstrates teamwork and effective communication to accomplish client, team, and Agency goals.
   • Participates in care conferences and other team or Agency meetings. Shares areas of expertise and initiates interdisciplinary referrals.
   • Educates team members and clients/families about community resources and how to access them appropriately.
4. Supervises the assessment, planning and implementation by the Social Service team.
5. Provides leadership to the interdisciplinary team and the Advisory Committee in identifying opportunities to improve services, and implement strategies to address unmet needs of clients.
6. Assists in the development, implementation, and evaluation of the ongoing quality improvement process.
   • Serves on the Clinical Record Review Committee and Professional Advisory Committee; attends meetings as required.
7. Performs other related duties and responsibilities as deemed necessary.