Social Worker
About the Role
An exciting opportunity has arisen for a Social Worker to join the Dublin South West Integrated Care Programme for Older Persons (ICPOP) Community Specialist Team.
The Community Specialist Team is a specialist transdisciplinary service supporting older people with complex care needs, frailty and multiple co-morbidities across the continuum of care.
The successful candidate will work as part of an experienced multidisciplinary team, providing specialist social work assessment, case management and support to older people and their families. The role involves working across community, primary care and acute hospital settings to ensure older people receive appropriate, person-centred and coordinated care.
This is an excellent opportunity for a Social Worker with an interest in older persons services, complex case management and integrated care.
About the Service
The overall aims of the Community Specialist Team are to:
- Provide specialist multidisciplinary assessment and support for older people with complex care needs.
- Develop person-centred care plans that promote continuity and effective communication across care settings.
- Support appropriate and timely reduction in Emergency Department attendance.
- Develop care pathways to support GPs and healthcare professionals in managing older people with escalating care needs.
- Provide education, advice and support to older people, their families, carers and healthcare professionals.
- Promote independence, dignity and quality of life for older people within their own communities.
The team uses a case management approach to assess and respond to the complex needs of frail older people.
Key Responsibilities
The successful Social Worker will:
- Manage a complex caseload of older people within the community.
- Complete comprehensive assessments of social, psychological and practical needs.
- Contribute to comprehensive geriatric assessment and multidisciplinary care planning.
- Develop person-centred care plans in partnership with older people, families and carers.
- Identify appropriate community and social care supports.
- Support older people to remain safely and appropriately within their own homes where possible.
- Advocate for the rights, wishes and preferences of older people.
- Provide support and advice to families and carers.
- Liaise with primary care, community and acute hospital services.
- Support timely transitions between care settings.
- Participate in multidisciplinary case discussions and team meetings.
- Contribute to the development and review of integrated care pathways.
- Maintain accurate and timely clinical documentation.
- Contribute to service evaluation, audit and quality improvement.
- Provide support and guidance to colleagues as part of a transdisciplinary model.
- Participate in supervision and continuing professional development.
Assisted Decision-Making & Capacity
The successful candidate will have knowledge and experience of the Assisted Decision-Making (Capacity) Act, including:
- Decision Support Service (DSS).
- Decision-Making Representative processes.
- Decision-Making Representation.
- Supporting individuals to exercise their will and preferences.
- Capacity assessment processes within the Social Work role.
- Rights-based and person-centred approaches to decision-making.
An understanding of safeguarding, advocacy and supporting autonomy will be highly important within this role.
Nursing Home Support Scheme
Experience and knowledge of the Nursing Home Support Scheme (Fair Deal) is essential for the role.
The successful candidate should be confident supporting older people and families with:
- Exploring long-term care options.
- Understanding the Nursing Home Support Scheme.
- Liaising with relevant services regarding applications and supports.
- Supporting families through complex care decisions.
- Exploring alternatives to residential care where appropriate.
Multidisciplinary Working
You will work as part of a highly collaborative transdisciplinary team, including:
- Consultant Geriatrician
- ICPOP Operational Lead
- Registrar
- Advanced Nurse Practitioner
- Clinical Nurse Manager
- Senior Physiotherapist
- Senior Occupational Therapist
- Social Worker
- Speech and Language Therapist
- Dietitian
- Physiotherapy Assistant
- Occupational Therapy Assistant
- Administration colleagues
The role requires flexibility and a willingness to support colleagues across the team in the management of complex caseloads.
Community & Primary Care Collaboration
The Social Worker will work closely with HSE primary care and community services, including:
- Public Health Nurses
- Health and Social Care Professionals
- Home Support Services
- Respite Services
- Nursing Home Support Office
- Day Care Services
- Community Mental Health Nursing
- Psychiatry of Later Life
You will also develop strong working relationships with community and voluntary organisations supporting older people.
These may include:
- SAGE Advocacy
- ALONE
- Family Carers Ireland
- Alzheimer Society of Ireland
- South Dublin County Council
- South Dublin Partnership
- Meals on Wheels
- An Garda Síochána
Acute Hospital Links
The Community Specialist Team works closely with colleagues in acute hospital services, including:
- Frailty at the Front Door / Geriatric Emergency Department Intervention teams.
- Ambulatory care and day hospital services.
- Gerontology teams.
- Nursing Home Outreach services.
- Specialist Memory Services.
- Falls Services.
- Psychiatry of Later Life.
The successful candidate will play an important role in ensuring effective communication and coordinated care between hospital and community services.
Case Management
All senior clinicians within the Community Specialist Team contribute to case management.
The Social Worker will:
- Manage complex patient caseloads.
- Coordinate services around the individual.
- Identify risks and barriers to safe discharge or community living.
- Coordinate communication between healthcare professionals.
- Identify appropriate social and community supports.
- Support older people and families through complex care decisions.
- Review care plans and outcomes.
- Escalate concerns appropriately.
- Ensure the person’s wishes, rights and preferences remain central to care planning.
Reporting Relationships
The successful candidate will:
- Operationally report to the ICPOP Operational Lead for line management.
- Professionally report to the relevant Head of Discipline for professional registration, supervision and clinical assurance.
- Operate under the clinical governance of the relevant Integrated Care Consultant Geriatrician.
Essential Requirements
Applicants must:
- Hold a recognised qualification in Social Work.
- Be registered, or eligible for registration, with the Social Workers Registration Board at CORU.
- Provide evidence of statutory registration before a contract of employment can be issued.
- Have the requisite knowledge, skills and professional ability to fulfil the role.
- Demonstrate experience relevant to working with older people and complex care needs.
- Have knowledge and experience of the Assisted Decision-Making (Capacity) Act.
- Have knowledge and experience of the Decision Support Service and DMRR processes.
- Have knowledge and experience of the Nursing Home Support Scheme (Fair Deal).
- Have excellent communication and interpersonal skills.
- Demonstrate strong assessment, advocacy and case-management skills.
- Be capable of working effectively as part of a multidisciplinary and transdisciplinary team.
- Have a full driving licence and access to their own transport, as the role involves community travel.
- Be willing to complete Garda Vetting.
About the author
