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Trinity Health Mercy Life MASS_Social Worker in West Springfield, Massachusetts

Mercy LIFE, a member of Trinity Health PACE, is seeking a Social Worker, for its location in W. Springfield, MA. The Program of All-Inclusive Care for the Elderly (PACE) model is centered on the belief that it is better for the well-being of seniors with chronic care needs and their families to be served in the community whenever possible. PACE serves individuals who are age 55 or older, certified by their state to need nursing home care, able to live safely in the community at the time of enrollment and live in a PACE service area. While all PACE participants must be certified to need nursing home care to enroll in PACE, only about 7 percent of PACE participants nationally reside in a nursing home. If a PACE enrollee needs nursing home care, the PACE program pays for it and continues to coordinate the enrollee's care. We encourage fellowship and independence while serving seniors and their families with dignity and respect. Delivering all needed medical and supportive services, PACE is able to provide the entire continuum of care and services to seniors with chronic needs while maintaining their independence in their home for as long as possible.

Under the supervision of the Center Director, plans, organizes and implements social work assessment, treatment, teaching and counseling to participants, caregivers or other appropriate representatives. Social Worker interventions may include, individual participant contacts, appropriate collateral contact, participant and family education, assessment, and counseling, provision of resources, addressing mental health needs as they arise, ongoing case management, advocacy to ensure participant and caregiver needs are met and addressed, and disenrollment procedures. The Social Worker is the liaison between the interdisciplinary team, caregiver representatives, and community agencies.

General responsibilities will include:

Performs in person initial assessments for enrollment of potential Mercy LIFE participants. Coordinates with the interdisciplinary team to develop a comprehensive care plan for each participant. Conducts in-person reassessments of enrolled participants every six months and as needed. Assists participants and caregivers to complete Medical Durable Power of Attorney (MDPOA), Proxy, and Do Not Resuscitate (DNR) directives as needed.

Functions as a member of the interdisciplinary team. Maintains regular attendance at and participates in interdisciplinary team meetings, communicates participant changes, and collaborates on care planning decisions and coordination for 24 hour care delivery.

Acts as liaison with participant, caregivers, and community agencies regarding orientation to and ongoing relations with interdisciplinary team, day center, and other Mercy LIFE staff, including volunteers.

On an annual basis (during annual or semiannual reassessment) presents the written participant rights documentation to assigned participants and or caregiver. In the event of termination of the PACE organization, the social worker will act to coordinate the transitional care necessary to ensure continuation of care during and after termination.

Provides ongoing support, counsel, and education to participants and family regarding a variety of issues. Performs home visits quarterly or as needed to assess living environment and support system. Will proactively work to partner with participant and/or caregivers to maintain appropriate housing and assist participant to function at most independent community level possible.

Presents requests to interdisciplinary team and coordinates admission/discharge to contracted facilities for temporary respites and permanent placement. Acts as facilitator for meetings with participant, family, caregivers, and community agencies to clarify, or problem solves issues regarding the Plan of Care. Mediates discussions between all parties. Assists participants and caregivers in filing grievances and appeals.

Performs visits within 24 hours of hospital admissions or on Monday if participant is admitted on Friday or weekend. Coordinates hospital discharges in conjunction with interdisciplinary team and communication with attending physician.

Assists participants and caregivers to set up and maintain Personal Needs Accounts. Assists participants with Social Security Income (SSI) and Social Security Disability Insurance (SSDI) application process as needed.

Assists participants and family to keep resources within guidelines for Medicaid eligibility.

Maintains high standards of business and ethical conduct in accordance with applicable federal, state and local laws and regulations including fraud, abuse and waste. Avoids activities, which could result in perceived or actual conflicts of interest. Maintains required licenses and certifications.

Candidates will have:

  • Education: Master’s degree in Social Work from an accredited school of Social Work required. Member of the Academy of Certified Social Workers (ACSW) or other NASW-recognized certification preferred.

  • Certification/License: Licensed with the Massachusetts Board of Social Work at a LCSW level or higher. Valid MA driver's license and ability to provide a reliable means of transportation required.

  • Minimum of two years’ experience as a social worker,one (1) year working with the frail or elderly required.

  • Ability to function with minimal supervision and ability to work in a multicultural, multi-ethnic environment. Demonstrates sensitivity to the unique needs of patients and families experiencing a serious or terminal illness.


Job Number: 00113974

Location: West Springfield, MA

Organization Name: Trinity Health PACE

Facility: SPMA - Hillside Prov

Employment Type: Full time

Shift: Day Shift

Hours: 40