MSW
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Master’s-level Social Workers
Created by Scolari Consulting
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Purpose of the Course
Welcome to your training as a Master’s-Level Social Worker in the PACE model.
In this unique role, you’ll step into homes, hospital rooms, and care team huddles—not just to assess, but to understand. You’ll listen between the lines, uncover silent risks and translate human experience into coordinated care.
This course will guide you through what it truly means to be a Social Worker in PACE, conducting biopsychosocial assessments, supporting families through complex transitions, advocating for dignity and documenting with purpose.
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Module 2
Module 1
Module 3
Module 4
Module 1
A Day in the Life of a PACE MSW
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introduction
Click on each item to learn why it matters
Three Core Actions of the MSW in PACE
Assess and Identify Needs
Conduct biopsychosocial assessments and identify emotional, social and environmental risks that affect the participant’s well-being.
Support and Connect
Provide counseling, crisis intervention, and caregiver support while linking participants to vital resources like housing, food and behavioral health.
Document to Drive Care
Clearly document findings and actions to influence the care plan, ensure compliance with 42 CFR §460.106 and protect participant rights and outcomes.
MODULE 1
A Day in the Life of a PACE MSW
Having Technical Issues?Click me
learning objectives
Click on each item to learn why it matters
By the end of this module, you will be able to:
Describe the daily responsibilities of the MSW in the PACE model, including assessment, advocacy, and care coordination.
Explain how MSWs address social, emotional, and environmental needs as part of participant-centered care.
Apply effective, compliant documentation practices using the 4C Formula.
MODULE 1
A Day in the Life of a PACE MSW
Having Technical Issues?Click me
key points
Click on each item to learn why it matters
Who is theMSW in PACE?
What MSWs Actually Do
MODULE 1
A Day in the Life of a PACE MSW
Having Technical Issues?Click me
Documentation:Care Coordination in Action
Compare the itemsin this table
The 4C Formula is a structured approach to documentation that ensures your notes are complete, regulatory-ready, and truly reflect the care delivered. It helps tie together observations, clinical insights, actions taken and IDT collaboration.
Click to Learn Why it Matters
MODULE 1
A Day in the Life of a PACE MSW
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Complete vs IncompleteDocumentation
Click on each item to learn why it matters
Vague Note:
“Participant seems withdrawn but okay. No concerns at this time”
4C Note:
“Participant alert but withdrawn (Clear Observation). Behavior suggests emotional decline post-hospitalization (Clinical Interpretation). Initiated psychosocial reassessment and scheduled home visit (Care Action). Communicated findings to IDT for review (Collaborative Next Steps).”
Click to Learn a Pro Tip
MODULE 1
A Day in the Life of a PACE MSW
Having Technical Issues?Click me
“No Heat, No Note?”
Click on the itemto learn why it matters
Let’s shadow Marisol again... You’re on a home visit to check in on Mr. Basilik, he’s quiet, wearing gloves indoors. The apartment is freezing. No active heat. When asked, he shrugs: “Trying to save money.” You offer a referral to the utility assistance program and jot down a plan to follow up. Back at the center, you mention it in the huddle—but the note you write?
“Home visit completed. Participant-oriented x3. There is no heat in the apartment.”
Let’s look at how to fix it using the 4C Formula:
MODULE 1
A Day in the Life of a PACE MSW
Having Technical Issues?Click me
Instruction:Multiple Choice
question 1
MODULE 1
A Day in the Life of a PACE MSW
Having Technical Issues?Click me
Instruction:True or False
question 2
MODULE 1
A Day in the Life of a PACE MSW
Having Technical Issues?Click me
Instruction:Drag the Word
question 3
MODULE 1
A Day in the Life of a PACE MSW
Having Technical Issues?Click me
Module 1Completed!
Click to Start Audio
Key Takeaways:
- Core members of the IDT – social workers are responsible for assessment, advocacy, and care coordination across every setting—home, center, and community.
- Ensure the delivery of participant-centered care - you see what’s unsaid and bring forward the emotional, social, and environmental factors that shape a participant’s health.
- Documentation is the bridge – you connect what you observe and what the team does next. Your notes drive care, ensure compliance and protect the rights and dignity of every participant.
Menu
Module 2
Module 1
Module 3
Module 4
Module 2
IDT Participation & Collaboration
Click to Play Audio
LEarning Objectives
Click on each item to learn why it matters
By the end of this module, you will be able to:
Explain how MSWs contribute to IDT communication and care planning
Identify key strategies for turning psychosocial insights into team-based actions
Apply the 4C Formula to document impactful psychosocial updates
MODULE 2
Having Technical Issues?Click me
IDT Participation & Collaboration
What Does Strong IDT Participation Look Like?
Compare the itemsin this table
MODULE 2
Having Technical Issues?Click me
IDT Participation & Collaboration
Common Pitfalls & How to Avoid Them
Compare the itemsin this table
MODULE 2
Having Technical Issues?Click me
IDT Participation & Collaboration
Documentation Spotlight
Click on the itemto learn why it matters
“He’s Just Lonely” Isn’t Enough
Click to Start Audio
Click to Learn a Pro Tip
MODULE 2
Having Technical Issues?Click me
IDT Participation & Collaboration
Instruction:Multiple Choice
question 1
MODULE 2
Having Technical Issues?Click me
IDT Participation & Collaboration
Instruction:True or False
question 2
MODULE 2
Having Technical Issues?Click me
IDT Participation & Collaboration
Instruction:Drag the Word
question 3
MODULE 2
Having Technical Issues?Click me
IDT Participation & Collaboration
Module 2Completed!
Click to Start Audio
Key Takeaways:
- MSWs contribute more than updates—they shape care planning by turning participant experiences into psychosocial insights that guide the team.
- The timing, tone, and clarity of your communication matter. Sharing early, using quotes and connecting emotions to function can activate the rest of the IDT to respond effectively.
- Strong documentation transforms your voice into continuity. What you observe, interpret and recommend—when clearly documented—helps ensure nothing gets lost between meetings.
Menu
Module 2
Module 1
Module 3
Module 4
Module 3
Care Coordination Acrossthe Continuum of Care
Click to Play Audio
LEarning Objectives
Click on each item to learn why it matters
By the end of this module, you will be able to:
Identify the MSW’s core responsibilities during each care transition
Spot psychosocial red flags that impact safety and outcomes
Apply the 4C Formula to document clearly across the continuum of care
MODULE 3
Having Technical Issues?Click me
Care Coordination Across the Continuum of Care
Step 1: at home
Click on each item to learn why it matters
A Quiet Crisis Begins at Home
Red Flags to Watch
MSW Role at This Stage
Best Practice
Click to Start Audio
MODULE 3
Having Technical Issues?Click me
Care Coordination Across the Continuum of Care
Step 2: Facility Entry
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When a Transfer Happens, You Carry the Story
Red Flags to Watch
MSW Role at This Stage
Documentation Spotlight
Click to Start Audio
MODULE 3
Having Technical Issues?Click me
Care Coordination Across the Continuum of Care
Step 3: During Stay
Click on each item to learn why it matters
Don’t Disappear During the Stay—Be Their Anchor
Red Flags to Watch
MSW Role at This Stage
Best Practice
Click to Start Audio
MODULE 3
Having Technical Issues?Click me
Care Coordination Across the Continuum of Care
Step 4: Return Home / Post-Discharge
Click on each item to learn why it matters
Coming Home Is Its Own Transition
Red Flags to Watch
MSW Role at This Stage
Documentation Spotlight
Click to Start Audio
MODULE 3
Having Technical Issues?Click me
Care Coordination Across the Continuum of Care
Instruction:Multiple Choice
question 1
MODULE 3
Having Technical Issues?Click me
Care Coordination Across the Continuum of Care
Instruction:True or False
question 2
MODULE 3
Having Technical Issues?Click me
Care Coordination Across the Continuum of Care
Instruction:Drag the Word
question 3
MODULE 3
Having Technical Issues?Click me
Care Coordination Across the Continuum of Care
Module 3Completed!
Click to Start Audio
Key Takeaways:
- Social Workers play a critical role across all stages of care transitions - anticipating needs, assessing risks and activating early support.
- You spot red flags others miss - Subtle changes at home or in behavior often signal deeper risks. Your early action prevents bigger problems.
- From insight into action – your documentation ensures continuity, compliance and participant-centered care after each transition.
Menu
Module 2
Module 1
Module 3
Module 4
Module 4
Real-World Practice & Application
Click to Play Audio
LEarning Objectives
Click on each item to learn why it matters
By the end of this module, you will be able to:
Analyze MSW responsibilities in real-time decision-making
Identify red flags that require psychosocial intervention
Apply the 4C Documentation Formula to complex participant cases
Coordinate psychosocial care across IDT and settings
MODULE 4
Having Technical Issues?Click me
Real-World Practice & Application
Case Study
Click on each item to learn why it matters
“Holding the Thread – The Story of Mr. Alvarez”
Participant: Mr. Luis AlvarezAge: 81Living Situation: Lives at home with adult daughter (caregiver)Conditions: CHF, diabetes, mild cognitive impairmentPsychosocial Factors: Widowed, Spanish-speaking only, emotionally withdrawn after wife’s death, reluctant to engage in therapy or support groups
Title
Background
Use this side to give more information about a topic.
Subtitle
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MODULE 4
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Real-World Practice & Application
Step 1: Missed Visitsand a Quiet Caregiver
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Situation:
Over the past 2 weeks, Mr. Alvarez has missed 3 center days. His daughter says he's “just tired.” Staff note he’s been less talkative when he does attend. He’s lost weight and seems distracted during meals.
Red Flags to Watch
MSW Actions
Documentation Spotlight
Click to Start Audio
MODULE 4
Having Technical Issues?Click me
Real-World Practice & Application
Step 2: Home Visit – “He’s Not the Same”
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Situation:
At the home, Mr. Alvarez appears disheveled. His daughter is agitated. She confides that she’s exhausted, working two jobs, and feels like she’s “losing him.” Mr. Alvarez keeps calling out his late wife’s name in the middle of the night.
Coaching Narration
MSW Actions
Best Practice Table
Click to Start Audio
MODULE 4
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Real-World Practice & Application
Step 3: Escalation During IDT
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Situation:
At the next IDT meeting, Liz presents her findings. The PCP suggests “watchful waiting,” unsure if grief counseling will help. The dietitian is concerned about Mr. Alvarez’s nutritional decline.
Documentation Spotlight
MSW Actions
Click to Start Audio
MODULE 4
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Real-World Practice & Application
Step 4: 3 Weeks Later – A Turning Point
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Situation:
Mr. Alvarez begins weekly grief visits with a bilingual counselor. He starts eating more regularly. His daughter uses a respite voucher for the first time. She joins a Spanish-language caregiver support group.
Coaching Narration
What Worked
Final Reflection
Click to Start Audio
MODULE 4
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Real-World Practice & Application
Instruction:True or False
question 1
MODULE 4
Having Technical Issues?Click me
Real-World Practice & Application
Instruction:Drag the Word
question 2
MODULE 4
Having Technical Issues?Click me
Real-World Practice & Application
Instruction:Arrange the Sequence
question 3
MODULE 4
Having Technical Issues?Click me
Real-World Practice & Application
Module 4Completed!
Click to Start Audio
Key Takeaways:
- Your daily role as an MSW goes beyond tasks—it's about listening deeply, advocating fiercely, and responding early.
- Your voice in IDT isn't optional—it's essential to truly participant-centered care.
- You are a bridge across the care continuum, ensuring transitions are supported, not just survived.
- Your 4C documentation is your compliance compass, but also your storytelling tool.
End-of-Course Reflection
- You are the voice that brings emotion, risk, and resilience into the care plan.What you observe and share can shape the entire team’s actions.
- Your role isn’t just supportive—it’s clinical, regulatory, and essential.You navigate assessments, transitions, grief, crises, and systems—often before anyone else sees the need.
- The quality of your documentation defines the continuity of care.Your clarity protects participants’ rights and ensures services follow through.
- Your silence can mean their story goes untold.Speak up early, document with precision and advocate even when it’s hard.
- You are not alone.The IDT is stronger when you lead with psychosocial insight.
Evaluation
Instruction:Multiple Choice
question 1
Final Evaluation
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PACE MSW
Instruction:True or False
question 2
Final Evaluation
Having Technical Issues?Click me
PACE MSW
Instruction:Drag the Word
question 3
Final Evaluation
Having Technical Issues?Click me
PACE MSW
Instruction:Arrange the Sequence
question 4
Final Evaluation
Having Technical Issues?Click me
PACE MSW
Instruction:Multiple Choice
question 5
Final Evaluation
Having Technical Issues?Click me
PACE MSW
Instruction:True or False
question 6
Final Evaluation
Having Technical Issues?Click me
PACE MSW
Instruction:Drag the Word
question 7
Final Evaluation
Having Technical Issues?Click me
PACE MSW
Instruction:Arrange the Sequence
question 8
Final Evaluation
Having Technical Issues?Click me
PACE MSW
Instruction:Multiple Choice
question 9
Final Evaluation
Having Technical Issues?Click me
PACE MSW
Instruction:Multiple Choice
question 10
Final Evaluation
Having Technical Issues?Click me
PACE MSW
Congratulations!
You’ve successfully completed your course—well done! Your commitment to learning, growing and improving your skills has truly paid off. By finishing this course, you’ve taken an important step in building new knowledge and strengthening your professional development. Keep up the great work, and remember that every skill you gain is an investment in your future.
Any questions?
👏
rosana.scolari@scolariconsulting.com www.scolariconsulting.com
Who is the MSW in PACE?
- Licensed social worker with a Master’s degree.
- Core member of the Interdisciplinary Team (IDT).
- Focused on psychosocial well-being, dignity, and access to resources.
- Serves as participant advocate, emotional support, and systems navigator.
Documentation Spotlight
Scenario: "Ms. Liu has been admitted to a Skilled Nursing Facility after a fall. The facility nurse reports she’s quiet and compliant." Bad Note: “Participant admitted to SNF after fall. No concerns noted by staff. Will continue to monitor.”
Red Flags to Watch
- Caregiver visibly overwhelmed
- Participant disengaged or anxious
- Home environment not suited to new mobility status
- DME delivered but not used
- No follow-up services initiated
What MSWs Actually Do
1. Assess Needs
Per 42 CFR § 460.104, conduct biopsychosocial initial assessments within 30 days of enrollment and semi-annually, or as needed to understand the full picture of the participant’s well-being.
2. Identify Risk Factors
Spot emotional, social, and environmental issues that may impact health, safety, or independence.
3. Provide Support
Offer counseling, crisis intervention, and guidance to participants and their caregivers during times of stress or change.
4. Connect to Services
Link participants to essential resources like housing, food, transportation, and behavioral health care.
5. Document for Action
Write clear, timely notes that support care coordination, regulatory compliance, and participant rights under 42 CFR §460.102.
Documentation Spotlight
Scenario: Ms. Jennifer was admitted to a SNF after a fall. She lives with her son, who seemed calm—but privately told the MSW: “I can’t handle this anymore. I just can’t.”Bad Note: “Participant admitted to SNF due to recent fall. Family aware of plan.”
Best Practice
Build trust before a crisis.Your early notes lay the foundation for IDT action when the situation escalates.
Red Flags to Watch
- Abrupt placement without family support
- No psychosocial summary sent with participant
- Facility unaware of behavioral health needs
- Participant disoriented or panicked by the move
️ Red Flags
Let’s look at how to fix it using the 4C Formula:
MSW Actions
- Advocates for active intervention, not passive observation
- Cites risk of psychosocial decline triggering medical events
- Suggests short-term in-home grief support and respite trial
- Offers to coordinate joint visit with RN for rapport-building
Best Practice
Your advocacy ensures the transition home is not just safe—but aligned with the participant’s values.
MSW Role at This Stage
Red Flags to Watch
- Missed Day Center visits with vague reasons
- Caregiver expressing exhaustion, frustration, or guilt
- Participant verbalizing “I don’t want to be a burden”
- Unkept home, unopened mail, or expired food
- Changes in mood, withdrawal from social activity
What Worked
Documentation Spotlight
Pro Tip:
When in doubt, ask yourself:“Does my note show what I saw, what I thought, what I did, and who else knows?”
If not — add the missing C.
Pro Tip:
“One quote, one observation, one action—telling a story, that’s all it takes to help the team see the person, not just the plan.”
Red Flags to Watch
- Participant isolated or emotionally distressed
- Facility social worker unaware of care preferences
- Conflicts within family around discharge decisions
- Behavioral issues triggering medication or restraint use
MSW Actions
- Reviews attendance, recent nursing notes, and his last psychosocial assessment
- Calls the daughter: she sounds rushed, says she’s “fine,” but avoids details
- Requests a home visit
Final Reflection
“In this case, it wasn’t a medical diagnosis that drove the crisis—it was silence, sadness, and caregiver strain.
The MSW's job is to see beneath the surface. Not just to ask what’s wrong, but what’s missing?
In Mr. Alvarez’s case, it was connection. And through her training, presence, and documentation, Liz helped restore it.”
MSW Role at This Stage
Coaching Narration
“This didn’t happen overnight. But it wouldn’t have happened at all without intervention.
Liz didn’t just react—she stayed engaged across weeks, settings, and disciplines. She didn’t assume the family would figure it out. She walked with them until they did.”
Documentation Spotlight
Instead of:
“Participant shows signs of grief. Discussed in IDT.”
Use 4C:
Best Practice Table
Coaching Narration
“This isn’t about checking boxes. It’s about connection. Liz doesn’t give her a handout—she gives her presence. She listens. And that alone shifts the daughter from shutdown to sharing.
You can’t fix grief. But you can be the person who helps the family survive it together.”
MSW Actions
- Normalizes caregiver emotions, validates distress
- Assesses for complicated grief and potential early dementia signs
- Initiates referral for caregiver support + respite options
- Provides grief education, explores cultural/religious resources
MSW Role at This Stage
MSW Role at This Stage
Why It Matters in PACE
- Ensures compliance with 42 CFR §460.102 documentation expectations
- Supports team-based planning and accountability
- Strengthens your role as a care coordinator, not just a service provider
- Tells the full story of the participant — not just a symptom or a service
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Transcript
MSW
Continue
Master’s-level Social Workers
Created by Scolari Consulting
Click or hover over any words or icons that blink, move, or change to explore the interactive content.
Welcome to Your Course!
Play or Pause Audio
Click to Reveal Information
This course is designed to be interactive and engaging. To get the most out of it, please remember:
Answer Quiz
Click or Hover to Reveal Information
Click or Hover to Reveal Information
Click or Hover to Reveal Information
Click or Hover to Reveal Information
Click to start over
Click to start evaluation
Click to navigate pages
Click to show interactive elements
+ Text button
Click to Reveal Information
These elements on the screen—will guide you, share info, and help you move forward.
Enjoy your learning journey—we’re here to support you every step of the way!
Purpose of the Course
Welcome to your training as a Master’s-Level Social Worker in the PACE model. In this unique role, you’ll step into homes, hospital rooms, and care team huddles—not just to assess, but to understand. You’ll listen between the lines, uncover silent risks and translate human experience into coordinated care. This course will guide you through what it truly means to be a Social Worker in PACE, conducting biopsychosocial assessments, supporting families through complex transitions, advocating for dignity and documenting with purpose.
Having Technical Issues?Click me
Menu
Module 2
Module 1
Module 3
Module 4
Module 1
A Day in the Life of a PACE MSW
Click to Play Audio
introduction
Click on each item to learn why it matters
Three Core Actions of the MSW in PACE
Assess and Identify Needs Conduct biopsychosocial assessments and identify emotional, social and environmental risks that affect the participant’s well-being.
Support and Connect Provide counseling, crisis intervention, and caregiver support while linking participants to vital resources like housing, food and behavioral health.
Document to Drive Care Clearly document findings and actions to influence the care plan, ensure compliance with 42 CFR §460.106 and protect participant rights and outcomes.
MODULE 1
A Day in the Life of a PACE MSW
Having Technical Issues?Click me
learning objectives
Click on each item to learn why it matters
By the end of this module, you will be able to:
Describe the daily responsibilities of the MSW in the PACE model, including assessment, advocacy, and care coordination.
Explain how MSWs address social, emotional, and environmental needs as part of participant-centered care.
Apply effective, compliant documentation practices using the 4C Formula.
MODULE 1
A Day in the Life of a PACE MSW
Having Technical Issues?Click me
key points
Click on each item to learn why it matters
Who is theMSW in PACE?
What MSWs Actually Do
MODULE 1
A Day in the Life of a PACE MSW
Having Technical Issues?Click me
Documentation:Care Coordination in Action
Compare the itemsin this table
The 4C Formula is a structured approach to documentation that ensures your notes are complete, regulatory-ready, and truly reflect the care delivered. It helps tie together observations, clinical insights, actions taken and IDT collaboration.
Click to Learn Why it Matters
MODULE 1
A Day in the Life of a PACE MSW
Having Technical Issues?Click me
Complete vs IncompleteDocumentation
Click on each item to learn why it matters
Vague Note:
“Participant seems withdrawn but okay. No concerns at this time”
4C Note:
“Participant alert but withdrawn (Clear Observation). Behavior suggests emotional decline post-hospitalization (Clinical Interpretation). Initiated psychosocial reassessment and scheduled home visit (Care Action). Communicated findings to IDT for review (Collaborative Next Steps).”
Click to Learn a Pro Tip
MODULE 1
A Day in the Life of a PACE MSW
Having Technical Issues?Click me
“No Heat, No Note?”
Click on the itemto learn why it matters
Let’s shadow Marisol again... You’re on a home visit to check in on Mr. Basilik, he’s quiet, wearing gloves indoors. The apartment is freezing. No active heat. When asked, he shrugs: “Trying to save money.” You offer a referral to the utility assistance program and jot down a plan to follow up. Back at the center, you mention it in the huddle—but the note you write? “Home visit completed. Participant-oriented x3. There is no heat in the apartment.”
Let’s look at how to fix it using the 4C Formula:
MODULE 1
A Day in the Life of a PACE MSW
Having Technical Issues?Click me
Instruction:Multiple Choice
question 1
MODULE 1
A Day in the Life of a PACE MSW
Having Technical Issues?Click me
Instruction:True or False
question 2
MODULE 1
A Day in the Life of a PACE MSW
Having Technical Issues?Click me
Instruction:Drag the Word
question 3
MODULE 1
A Day in the Life of a PACE MSW
Having Technical Issues?Click me
Module 1Completed!
Click to Start Audio
Key Takeaways:
Menu
Module 2
Module 1
Module 3
Module 4
Module 2
IDT Participation & Collaboration
Click to Play Audio
LEarning Objectives
Click on each item to learn why it matters
By the end of this module, you will be able to:
Explain how MSWs contribute to IDT communication and care planning
Identify key strategies for turning psychosocial insights into team-based actions
Apply the 4C Formula to document impactful psychosocial updates
MODULE 2
Having Technical Issues?Click me
IDT Participation & Collaboration
What Does Strong IDT Participation Look Like?
Compare the itemsin this table
MODULE 2
Having Technical Issues?Click me
IDT Participation & Collaboration
Common Pitfalls & How to Avoid Them
Compare the itemsin this table
MODULE 2
Having Technical Issues?Click me
IDT Participation & Collaboration
Documentation Spotlight
Click on the itemto learn why it matters
“He’s Just Lonely” Isn’t Enough
Click to Start Audio
Click to Learn a Pro Tip
MODULE 2
Having Technical Issues?Click me
IDT Participation & Collaboration
Instruction:Multiple Choice
question 1
MODULE 2
Having Technical Issues?Click me
IDT Participation & Collaboration
Instruction:True or False
question 2
MODULE 2
Having Technical Issues?Click me
IDT Participation & Collaboration
Instruction:Drag the Word
question 3
MODULE 2
Having Technical Issues?Click me
IDT Participation & Collaboration
Module 2Completed!
Click to Start Audio
Key Takeaways:
Menu
Module 2
Module 1
Module 3
Module 4
Module 3
Care Coordination Acrossthe Continuum of Care
Click to Play Audio
LEarning Objectives
Click on each item to learn why it matters
By the end of this module, you will be able to:
Identify the MSW’s core responsibilities during each care transition
Spot psychosocial red flags that impact safety and outcomes
Apply the 4C Formula to document clearly across the continuum of care
MODULE 3
Having Technical Issues?Click me
Care Coordination Across the Continuum of Care
Step 1: at home
Click on each item to learn why it matters
A Quiet Crisis Begins at Home
Red Flags to Watch
MSW Role at This Stage
Best Practice
Click to Start Audio
MODULE 3
Having Technical Issues?Click me
Care Coordination Across the Continuum of Care
Step 2: Facility Entry
Click on each item to learn why it matters
When a Transfer Happens, You Carry the Story
Red Flags to Watch
MSW Role at This Stage
Documentation Spotlight
Click to Start Audio
MODULE 3
Having Technical Issues?Click me
Care Coordination Across the Continuum of Care
Step 3: During Stay
Click on each item to learn why it matters
Don’t Disappear During the Stay—Be Their Anchor
Red Flags to Watch
MSW Role at This Stage
Best Practice
Click to Start Audio
MODULE 3
Having Technical Issues?Click me
Care Coordination Across the Continuum of Care
Step 4: Return Home / Post-Discharge
Click on each item to learn why it matters
Coming Home Is Its Own Transition
Red Flags to Watch
MSW Role at This Stage
Documentation Spotlight
Click to Start Audio
MODULE 3
Having Technical Issues?Click me
Care Coordination Across the Continuum of Care
Instruction:Multiple Choice
question 1
MODULE 3
Having Technical Issues?Click me
Care Coordination Across the Continuum of Care
Instruction:True or False
question 2
MODULE 3
Having Technical Issues?Click me
Care Coordination Across the Continuum of Care
Instruction:Drag the Word
question 3
MODULE 3
Having Technical Issues?Click me
Care Coordination Across the Continuum of Care
Module 3Completed!
Click to Start Audio
Key Takeaways:
Menu
Module 2
Module 1
Module 3
Module 4
Module 4
Real-World Practice & Application
Click to Play Audio
LEarning Objectives
Click on each item to learn why it matters
By the end of this module, you will be able to:
Analyze MSW responsibilities in real-time decision-making
Identify red flags that require psychosocial intervention
Apply the 4C Documentation Formula to complex participant cases
Coordinate psychosocial care across IDT and settings
MODULE 4
Having Technical Issues?Click me
Real-World Practice & Application
Case Study
Click on each item to learn why it matters
“Holding the Thread – The Story of Mr. Alvarez”
Participant: Mr. Luis AlvarezAge: 81Living Situation: Lives at home with adult daughter (caregiver)Conditions: CHF, diabetes, mild cognitive impairmentPsychosocial Factors: Widowed, Spanish-speaking only, emotionally withdrawn after wife’s death, reluctant to engage in therapy or support groups
Title
Background
Use this side to give more information about a topic.
Subtitle
Click to Start Audio
MODULE 4
Having Technical Issues?Click me
Real-World Practice & Application
Step 1: Missed Visitsand a Quiet Caregiver
Click on each item to learn why it matters
Situation:
Over the past 2 weeks, Mr. Alvarez has missed 3 center days. His daughter says he's “just tired.” Staff note he’s been less talkative when he does attend. He’s lost weight and seems distracted during meals.
Red Flags to Watch
MSW Actions
Documentation Spotlight
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MODULE 4
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Real-World Practice & Application
Step 2: Home Visit – “He’s Not the Same”
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Situation:
At the home, Mr. Alvarez appears disheveled. His daughter is agitated. She confides that she’s exhausted, working two jobs, and feels like she’s “losing him.” Mr. Alvarez keeps calling out his late wife’s name in the middle of the night.
Coaching Narration
MSW Actions
Best Practice Table
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MODULE 4
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Real-World Practice & Application
Step 3: Escalation During IDT
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Situation:
At the next IDT meeting, Liz presents her findings. The PCP suggests “watchful waiting,” unsure if grief counseling will help. The dietitian is concerned about Mr. Alvarez’s nutritional decline.
Documentation Spotlight
MSW Actions
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MODULE 4
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Real-World Practice & Application
Step 4: 3 Weeks Later – A Turning Point
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Situation:
Mr. Alvarez begins weekly grief visits with a bilingual counselor. He starts eating more regularly. His daughter uses a respite voucher for the first time. She joins a Spanish-language caregiver support group.
Coaching Narration
What Worked
Final Reflection
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MODULE 4
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Real-World Practice & Application
Instruction:True or False
question 1
MODULE 4
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Real-World Practice & Application
Instruction:Drag the Word
question 2
MODULE 4
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Real-World Practice & Application
Instruction:Arrange the Sequence
question 3
MODULE 4
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Real-World Practice & Application
Module 4Completed!
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Key Takeaways:
End-of-Course Reflection
Evaluation
Instruction:Multiple Choice
question 1
Final Evaluation
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PACE MSW
Instruction:True or False
question 2
Final Evaluation
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PACE MSW
Instruction:Drag the Word
question 3
Final Evaluation
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PACE MSW
Instruction:Arrange the Sequence
question 4
Final Evaluation
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PACE MSW
Instruction:Multiple Choice
question 5
Final Evaluation
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PACE MSW
Instruction:True or False
question 6
Final Evaluation
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PACE MSW
Instruction:Drag the Word
question 7
Final Evaluation
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PACE MSW
Instruction:Arrange the Sequence
question 8
Final Evaluation
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PACE MSW
Instruction:Multiple Choice
question 9
Final Evaluation
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PACE MSW
Instruction:Multiple Choice
question 10
Final Evaluation
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PACE MSW
Congratulations!
You’ve successfully completed your course—well done! Your commitment to learning, growing and improving your skills has truly paid off. By finishing this course, you’ve taken an important step in building new knowledge and strengthening your professional development. Keep up the great work, and remember that every skill you gain is an investment in your future.
Any questions?
👏
rosana.scolari@scolariconsulting.com www.scolariconsulting.com
Who is the MSW in PACE?
Documentation Spotlight
Scenario: "Ms. Liu has been admitted to a Skilled Nursing Facility after a fall. The facility nurse reports she’s quiet and compliant." Bad Note: “Participant admitted to SNF after fall. No concerns noted by staff. Will continue to monitor.”
Red Flags to Watch
What MSWs Actually Do
1. Assess Needs Per 42 CFR § 460.104, conduct biopsychosocial initial assessments within 30 days of enrollment and semi-annually, or as needed to understand the full picture of the participant’s well-being. 2. Identify Risk Factors Spot emotional, social, and environmental issues that may impact health, safety, or independence. 3. Provide Support Offer counseling, crisis intervention, and guidance to participants and their caregivers during times of stress or change. 4. Connect to Services Link participants to essential resources like housing, food, transportation, and behavioral health care. 5. Document for Action Write clear, timely notes that support care coordination, regulatory compliance, and participant rights under 42 CFR §460.102.
Documentation Spotlight
Scenario: Ms. Jennifer was admitted to a SNF after a fall. She lives with her son, who seemed calm—but privately told the MSW: “I can’t handle this anymore. I just can’t.”Bad Note: “Participant admitted to SNF due to recent fall. Family aware of plan.”
Best Practice
Build trust before a crisis.Your early notes lay the foundation for IDT action when the situation escalates.
Red Flags to Watch
️ Red Flags
Let’s look at how to fix it using the 4C Formula:
MSW Actions
Best Practice
Your advocacy ensures the transition home is not just safe—but aligned with the participant’s values.
MSW Role at This Stage
Red Flags to Watch
What Worked
Documentation Spotlight
Pro Tip:
When in doubt, ask yourself:“Does my note show what I saw, what I thought, what I did, and who else knows?” If not — add the missing C.
Pro Tip:
“One quote, one observation, one action—telling a story, that’s all it takes to help the team see the person, not just the plan.”
Red Flags to Watch
MSW Actions
Final Reflection
“In this case, it wasn’t a medical diagnosis that drove the crisis—it was silence, sadness, and caregiver strain. The MSW's job is to see beneath the surface. Not just to ask what’s wrong, but what’s missing? In Mr. Alvarez’s case, it was connection. And through her training, presence, and documentation, Liz helped restore it.”
MSW Role at This Stage
Coaching Narration
“This didn’t happen overnight. But it wouldn’t have happened at all without intervention. Liz didn’t just react—she stayed engaged across weeks, settings, and disciplines. She didn’t assume the family would figure it out. She walked with them until they did.”
Documentation Spotlight
Instead of: “Participant shows signs of grief. Discussed in IDT.” Use 4C:
Best Practice Table
Coaching Narration
“This isn’t about checking boxes. It’s about connection. Liz doesn’t give her a handout—she gives her presence. She listens. And that alone shifts the daughter from shutdown to sharing. You can’t fix grief. But you can be the person who helps the family survive it together.”
MSW Actions
MSW Role at This Stage
MSW Role at This Stage
Why It Matters in PACE