Social Worker - Dementia Navigation Services (BSW)

Responsibilities

• Care Navigation & Coordination
• Conduct initial and ongoing assessments of individuals with dementia and their caregivers to identify needs, preferences, and barriers.
• Develop and implement individualized service plans in collaboration with clients, families, and interdisciplinary teams.
• Connect clients to appropriate medical, behavioral health, social, and community-based services (e.g., home health, adult day services, and respite care).
• Assist with transitions of care, including hospital discharge, long-term care placement, or in-home support expansion as needed.
• Client & Caregiver Support
• Provide education on dementia progression, caregiving strategies, and available resources.
• Offer emotional support and guidance to caregivers, addressing stress, burnout, and coping strategies.
• Advocate for client rights, dignity, and person-centered care approaches.
• Resource Navigation
• Maintain knowledge of local, state, and federal programs (e.g., Medicaid waivers, aging services, transportation, housing supports).
• Assist clients with applications, referrals, and eligibility processes.
• Coordinate with community partners to ensure continuity of care.
• Monitoring & Follow-Up
• Monitor client progress and reassess needs monthly.
• Document all client interactions, care plans, and service outcomes in accordance with organizational and regulatory standards.
• Identify and address safety concerns, including risks related to wandering, medication, adherence, or neglect.
• Collaboration
• Work closely with healthcare providers, case managers, and community organizations.
• Participate in interdisciplinary team meetings and case reviews.
• Support outreach efforts and community education related to dementia services.
• Provides psychosocial assessments of patients and families to identify emotional, social, and environmental strengths and problems related to their preventative health management, diagnosis, illness, treatment, and/or life situation.
• Utilizes social work experience to plan and coordinate patient care.
• Monitors healthcare resource utilization such as ED, urgent care, admissions, or frequent office visits. Collaborates with team to address unnecessary utilization and plans for appropriate support to modify process behaviors.
• Participates in care transitions planning and post-discharge follow up to assess psychosocial and support needs and reinforces patient self-management expectations and goals.
• Collaborates with other professionals to evaluate patients' medical or physical condition and to assess patient needs.
• Refers patient or family to

Benefits

Additional Information

Employment Status: Full time Shift: Day (United States of America) Facility: 1615 Franklin Rd - Roanoke Requisition Number: R160386 Social Worker - Dementia Navigation Services (BSW) (Open) How You'll Help Transform Healthcare: In collaboration with the health care team, the social worker assists patients and families with personal and environmental difficulties with predisposed illness or interferes with obtaining maximum benefits from medical care. Services include providing patient and families with the psychosocial support needed to cope with disease and life limiting illness, advising family and caregivers, providing education and support, and making referrals for other services as needed or requested. Social Worker - Dementia Navigation Services (BSW) within Homecare Services. This will be a grant funded position for the Navigation program, starting out as a 1-year position conditional upon grant funded agreement being extended. Company equipment. Position Summary The Social Worker (BSW) provides care navigation, resource coordination, and supportive services to individuals living with dementia and their caregivers. This role focuses on guiding clients through healthcare, community resources, and long-term support systems while promoting quality of life, safety, and independence.

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