Performs patient assessments and collaborates with the care team to develop and implement a plan of care. Makes referrals to other disciplines as indicated by the patient's identified needs or documents rationale for not doing so. Promotes patient health and independence through teaching and appropriate rehabilitative measures, assisting patients in learning appropriate s

Assists the patient and family with health related financial, social and emotional concerns and assists with effective coping skills. Provides social work services in accordance with the plan of care. Ensures that changes in the patient's clinical status are communicated to other healthcare team members and the care center office staff in a timely manner. Educates the pat

Educates health care professionals, patients, and families about home care services. Develops and maintains relationships with key referral sources, such as hospitals, nursing homes and physician offices to generate leads. Coordinates patient admissions with the team, including obtaining all required documentation to complete referral to admission process. Conducts on sit