The primary role of the Medical Social Worker II in the Hospice/Home Health setting is to assist patients and families/caregivers to cope with the social/ emotional issues and practical arrangements related to the patients illness. Under general direction, delivers age-appropriate social work care to patients and their caregivers in their place of residence in accordance with agency policy and procedure and state and federal regulations. The Medical Social Worker II serves as an integral member of the home health team providing assessments, coordination and implementation of social work services to meet the complex needs of patients in the home setting.

• Hospital/Clinic:
• Provides psychodynamic interventions, crisis intervention, grief/bereavement counseling, problem solving, stress reduction and developing healthy coping strategies in individual/family/group settings. Provide counseling for disease acceptance and understanding.
• Responsible for developing and implementing individual Plan of Treatment which assist patients and families to cope and/or restore social, emotional, financial and environmental factors which affect and/or affected by illness.
• Completes psychosocial assessments. Partners with patient to identify needs and develop and implement individual treatment plan based on mutually agreed upon treatment plan.
• Discuss options for care proactively including Kaiser resources and external community/government resources to assist patient and family in developing short and long term care plans as appropriate.
• Team with other disciplines in assessing, planning and providing services for patients utilizing biopsychosocial information.
• Assist patient in advocating for self to receive appropriate services within Kaiser and in the community.
• Assist patient and family with care planning and discharge plans.
• Takes, reviews, evaluates and prioritizes written and oral referrals.
• Maintains documentation, records and data collections.
• Responsible for completion of required documents in a complete and timely manner.
• Functions as part of the Skilled Nursing Facility Team to assure appro priate, timely placement of Kaiser members in nursing facilities.
• Liaison between patient and Kaiser maintaining positive relationship with Kaiser and providing for continuity of care.
• Identifies appropriate levels of care and facilities for referred patients, were applicable.
• Obtains placements, where applicable.
• Collaborate with internal and external resources in Kaiser and the community to meet mutually agreed upon goals and objectives.
• Provides information and referral to community resources as requested.
• Coordinates exchange of information between Kaiser, families, members and skilled nursing facilities.
• Determines application of Kaiser, Medicare and Medi-Cal benefits to specific patient situations.
• Participates in Utilization Management/Quality Assurance activities.
• Assist in coordinating communication between regional offices, clinics, hospitals, and field staff, triaging of phone calls from members/families.
• Works with referral sources to clarify and complete required clinical and psychosocial information.
• Perform other related duties as necessary.
• Hospice/Home Health:
• Provide psychodynamic interventions, crisis intervention, grief/bereavement counseling, problem solving, stress reduction and developing healthy coping strategies in individual/family/group settings.
• Provide counseling to help patients cope with acute/chronic/terminal illnesses.
• Responsible for developing and implementing individual Plan of Treatment which assist patients and families to cope and/or restore social, emotional, financial and environmental factors which affect and/or affected by illness.
• Completes biopsychosocial strengths based assessments.
• Partners with patient to identify needs and develop and implement individual treatment plan based on mutually agreed upon treatment plan.
• Discuss options for care proactively including Kaiser resources and external community/government resources to assist patient and family in developing short and long term care plans as appropriate.
• Team with other disciplines in assessing, planning and providing services for patients utilizing biopsychosocial information.
• Assist patient in advocating for self to receive appropriate services within Kaiser and in the community.
• Assist patient and family in placing patient in higher level of care as determined by team and patient, if applicable.
• Takes, reviews, evaluates and prioritizes written and oral referrals.
• Maintains documentation, records and data collections.
• Responsible for completion of required documents in a complete and timely manner.
• Functions as part of the Home Health/Hospice Team to assure appropriate, timely placement of Kaiser members in nursing facilities.
• Liaison between patient and Kaiser maintaining positive relationship with Kaiser and providing for continuity of care.
• Identifies appropriate levels of care and facilities for referred patients, where applicable. Obtains placements, where applicable.
• Collaborate with internal and external resources in Kaiser and the community to meet mutually agreed upon goals and objectives.
• Provides information and referral to community resources as requested.
• Coordinates exchange of information between Kaiser, families, members and skilled nursing facilities.  Determines application of Kaiser, Medicare and Medi-Cal benefits to specific patient situations.
• Participates in Quality Assurance activities as assigned.
• Assist in coordinating communication between regional offices, clinics, hospitals, and field staff, triaging of phone calls from members/families.
• Works with referral sources to clarify and complete required clinical and psychosocial information.
• Perform other related duties as necessary.
• Medi-Cal Health Care Coordination
• Identifies high and rising risk members in accordance to state and federal regulatory requirements such as DHCS Policy Requirement Guidelines and other All Plan Letters, (APLs).
• Coordinates development of care plan.  Identifies appropriate levels of care and facilities for referred patients, where applicable. Provides transitional care services.  Obtains placements, where applicable. Completes authorization/order requests. Works collaboratively with internal and external multi-disciplinary Care Team members in assessing, planning and providing services.
• Schedules preventative service appointments. Conducts in-person visits. Completes biopsychosocial assessments that meet all California State and Federal regulatory requirements.
• Assists patient and family, household member and caregiver in placing patient in higher level of care as determined by team and patient, if applicable. Connects Members with KP and community-based resources. Assists members in navigation across care settings and delivery systems. Utilizes motivational interventions to motivate member and caregiver engagement in care coordination and care plan activities. Assists patient in advocating for self to receive appropriate services w/in Kaiser Permanente and in the community.
• Liaison between patient and Kaiser maintaining positive relationship with Kaiser and providing for continuity of care. Assists in coordinating communication between regional offices, clinics, hospitals, and field staff, triaging of phone calls from members families. Ensures communication and information sharing on a continuous basis and facilitate access to needed services for members.
• Provides internal and external information and referrals to resources utilizing Kaiser Permanentes tools, resources, and technology platforms as appropriate. Participates in multi-disciplinary rounds. Collaborates with internal and external resources in Kaiser and the community to meet mutually agreed upon goals and objectives. Manages and prioritizes internal and external referrals assuring Kaiser responds within California State and Federal regulatory timeline. Responds to referrals in department and regulatory timelines.
• Responsible for completion of required documentation meeting department and regulatory timeline requirements, such as: mutually agreed upon care plans that address care gaps, barriers, interventions, and follow up plan. Maintains accurate records, documentation, data collection including operational data.
• Participates in quality assurance, utilization management/authorization activities as assigned. Conducts and participates in quality audits in preparation for State regulatory audits.
• Participates in improvement projects focused on access to services and quality of care. Assists in the development of training documents and workflows.
• Performs other related duties as necessary.

• Provide psychodynamic interventions, crisis intervention, grief/bereavement counseling, problem solving, stress reduction and developing healthy coping strategies in individual/family/group settings.
• Provide counseling to help patients cope with acute/chronic/terminal illnesses.
• Responsible for developing and implementing individual Plan of Treatment which assist patients and families to cope and/or restore social, emotional, financial and environmental factors which affect and/or affected by illness.
• Completes biopsychosocial strengths based assessments.
• Partners with patient to identify needs and develop and implement individual treatment plan based on mutually agreed upon treatment plan.
• Discuss options for care proactively including Kaiser resources and external community/government resources to assist patient and family in developing short and long term care plans as appropriate.
• Team with other disciplines in assessing, planning and providing services for patients utilizing biopsychosocial information.
• Assist patient in advocating for self to receive appropriate services within Kaiser and in the community.
• Assist patient and family in placing patient in higher level of care as determined by team and patient, if applicable.
• Takes, reviews, evaluates and prioritizes written and oral referrals.
• Maintains documentation, records and data collections.
• Responsible for completion of required documents in a complete and timely manner.
• Functions as part of the Home Health/Hospice Team to assure appropriate, timely placement of Kaiser members in nursing facilities.
• Liaison between patient and Kaiser maintaining positive relationship with Kaiser and providing for continuity of care.
• Identifies appropriate levels of care and facilities for referred patients, where applicable. Obtains placements, where applicable.
• Collaborate with internal and external resources in Kaiser and the community to meet mutually agreed upon goals and objectives.
• Provides information and referral to community resources as requested.
• Coordinates exchange of information between Kaiser, families, members and skilled nursing facilities.  Determines application of Kaiser, Medicare and Medi-Cal benefits to specific patient situations.
• Participates in Quality Assurance activities as assigned.
• Assist in coordinating communication between regional offices, clinics, hospitals, and field staff, triaging of phone calls from members/families.
• Works with referral sources to clarify and complete required clinical and psychosocial information.
• Perform other related duties as necessary.