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Delivers services and/or establishes benchmarks addressing the social and/or emotional factors that impact the clients' capacity to achieve the objectives of the Plan of Care.

Services are rendered under the guidance of a physician and in collaboration with other members of the healthcare team, adhering to the established policies and practices of the Agency.

KEY RESPONSIBILITIES/AREAS OF RESPONSIBILITY

1. Evaluates the psychosocial condition of clients to identify factors that may hinder the client's progress toward objectives.
   • Conducts assessments promptly and in accordance with Agency regulations.
   • Creates a written plan to provide guidance and information to other members of the healthcare team.
   • Records all findings, plans, interventions, and client progress in the clinical record.
   • Communicates plans and updates to the physician and/or nursing supervisor, as well as other Agency personnel, through the care plan, written progress notes, and participation in care conferences.
   • Initiates appropriate referrals.
2. Prepares social histories to supplement existing services or assist in determining or altering the level of service. This may entail considering cultural factors, financial concerns, and support systems.
3. Displays teamwork and effective communication to accomplish client, team, and Agency objectives.
   • 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 the appropriate methods for accessing them.
4. Supervises the assessment, planning, and implementation performed by the Social Service team.
5. Provides leadership to the interdisciplinary team and the Advisory Committee in identifying opportunities to enhance services and formulates strategies to address the unmet needs of clients.
6. Aids in the development, implementation, and assessment of the ongoing quality improvement process.
   • Serves on the Clinical Record Review Committee and Professional Advisory Committee; attends mandatory meetings.
7. Performs other relevant duties and responsibilities as required.