Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.

Fallon Health operates the largest Program of All-Inclusive Care for the Elderly (PACE) in New England and the fifth largest in the country. Called Summit ElderCare, Fallon’s PACE helps provide older adults and their caregivers with a welcome alternative to nursing home care. Participants in Summit ElderCare have access to comprehensive medical services and social support at a Summit ElderCare site while they keep the independence of living in their own homes and communities.

• Participates in the intake and evaluation process by conducting the initial social work assessment, administering MSQs, developing an intake summary and presenting the social work perspective to the Interdisciplinary Team.
• Assures that participants rights are reviewed during the intake process.
• Conducts reassessments at least semiannually and whenever there is a change in participant status or the participant /caregiver requests it.
• Develops and implements a social service plan of care for each participant and updates it based on the results of reassessments or on-going changes in status.
• Responsible for the maintenance of appropriate records and documentation in the medical record including at least the initial assessment, quarterly progress notes, significant changes and all participant-related interactions.
• Participates as a member of the Interdisciplinary Team at daily team meetings and care planning meetings.
• Assists team members to understand the social, emotional, cultural and psychosocial aspecst of participants’ situations.
• Acts as an advocate and liaison when counseling services are needed.
• Completes documentation and record-keeping related to disenrollment’s, deaths and permanent placement;distributes relevant notifications.
• Participates in the development, promotion and implementation of caregiver support groups or programs; leads or co-leads groups as necessary.
• Assists in managing referral telephone calls as needed.
• Implements program policies and procedures as directed.
• Assists in the conversion of participants from community based Medicaid to long-term care Medicaid when necessary. Works collaboratively with the Operations Support Representative to assure appropriate access to Medicaid benefits.
• Pursues relevant professional development. Attends appropriate workshops and in-service activities to maintain current professional status.
• Consistently follows the Social Work Code of Ethics.
• Performs all duties in accordance with Fallon Health and Summit ElderCare policies and procedures.