HarmonyCares is one of the nation’s largest home-based primary care practices. HarmonyCares is a family of companies all dedicated to providing high-quality, coordinated health care in the home. This includes HarmonyCares, HarmonyCares Medical Group, HarmonyCares Home Health and HarmonyCares Hospice.

Our Mission – To bring personalized, quality-based healthcare to the home of patients who have difficult accessing care.

Our Shared Vision – Every patient deserves access to quality healthcare.

Our Values – The way we care is our legacy. Every interaction counts. Go the extra mile. Empower and support each other.

The Clinical Social Worker works collaboratively with the Care Team to provide care management services and helps address an individual’s ability to maintain independence in the home, chronic care management, end of life decisions, cognitive/functional status, frequency acute care utilization, and a patient/caregiver support system. As a Clinical Social Worker you will:

• Manage a caseload of high risk socially complex patients
• Conduct face to face and telephonic psychosocial assessment with the patient and/or the caregiver
• Investigate psychological and social determinant barriers and design appropriate interventions to assist in closing gaps in care and needs
• Coordinate services to ensure the patient/family understands a treatment plan
• Provide outreach to community based services to support the patient’s ability to age at home
• Develop and implement shared goals of care with the patient and family
• Provide feedback to the home based primary care physician(HBPCP) to ensure he/she is aware of any early patient changes
• Participate in Multidisciplinary Care Planning Rounds
• Conduct additional psychosocial assessments as patient needs change
• Work with Community based agencies to develop relationships and provide appropriate resources to assist in maintaining patient independence
• Other duties/projects as assigned
• Participates in quality improvement activities aimed to improve patient-population outcomes and associated processes.