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Social Worker-Field

Company name
Aspire Health

Grand Rapids, MI

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Aspire Health is the nation’s largest community-based palliative care provider. Aspire specializes in providing an extra layer of support to patients facing a serious illness through an ambitious palliative care program focused on caring for patients in their homes and outpatient clinics. Aspire’s clinicians are experts in providing patients with relief from the symptoms, pain, and stress of a serious illness; helping patients and caregivers navigate the healthcare system; guiding patients and caregivers through difficult and complex treatment choices; and providing emotional and spiritual support to patients and their families.The Aspire Health Social Worker is responsible for providing supportive and medical social services to patients and their families in the home. This will include a range of tasks such as directly providing support to Aspire’s patients and families in the home as well as coordinating patient transition from facility to the home. The Aspire Social Worker assists the medical team in completing a comprehensive psycho­social assessment and subsequently establishing a patient’s plan of care in alignment with the care team. The Social Worker would establish and advocate for support services to patients and families, as well as care plans that are sensitive to the patient’s unique psychosocial needs, health status, and overall goals and values. Responsibilities will be highly varied, and appropriate candidates will be multitalented, flexible problem solvers who are eager to tackle complex problems and tasks. Ideal candidates will have experience identifying and coordinating the needs of chronically ill patients and families as well as supporting clinicians to help them operate as efficiently as possible. Provide in home and telephonic psychosocial assessment and supportive services to patients and families as part of an interdisciplinary team. Care coordination with the patient, family, caregivers, and other providers includes:Supporting hospice consultation and transitionGoals of care discussions and education on treatment plan recommendations at end of lifeSocial support and transportation needsFinancial counselingIdentifying non­clinical community resourcesMitigating family dynamics and patient compliance issuesAssess, identify, and close clinical and non­clinical gaps in patient careAppropriate triage and escalation of routine, urgent and emergent patient callsDocument social work assessments, care plans, and interventionsCollaboration with field based NPs\/PAs and physicians to develop and implement effective treatment plans and interventions for complex patient care issueIdentifying community resources and assisting Aspire’s patients and families in accessing those resourcesReferral to Aspire Health chaplain resources when appropriateProvide grief support and reassurance to patients and family membersParticipation in weekly interdisciplinary team meetingsPerform miscellaneous job-related duties as assignedRegular attendance is an essential function of the jobPrior healthcare experience serving chronically ill patients living with limited resources, and\/or mental illness preferredHealth plan, home health, or hospice experience a plusTelephonic case management or care coordination experience preferredStrong customer service orientationPatient, compassionate, and professional demeanor requiredExceptional organizational skills and ability to multi­taskSelf-starter with an entrepreneurial spirit and demonstrated problem solving skillsStrong writing, Word, Excel, and database management skillsExtremely strong work ethicExperience working in a fast-growing, rapidly changing environmentMust have reliable automobile, valid driver’s license and minimum state required liability auto insurance; Social Workers travel in personal vehicle with reimbursement for mileageBilingual is a plus Master’s degree in social work and licensure at that level requiredMinimum of 3 years social work experience required, preferably in a centralized care management team environment

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Aspire Health

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