Home HealthSocial Worker (Laf-1.0_

Complete initial and ongoing assessments covering the psychosocial, financial, cultural, and emotional patient environment. Determine social, psychological, cultural, and financial situations impacting the patient's plan, then establish a realistic plan of care with measurable goals. Initiate discharge planning and consult with physicians, nurses, case managers, and other disciplines regarding patient progress. Document assessments and pertinent information in a timely manner while collaborating with patients, caregivers, and outside agencies for care coordination. Evaluate patient progress and update the plan of care on a regular basis. Travel is required up to 75% of the time.