Social Worker
3 months ago
- Provide psychosocial assessments of patients and families to identify emotional, social, and environmental strengths and problems related to their diagnosis, illness, treatment, and/or life situation.
- Captures all legitimate revenue; conservative in expense and resource use yet provides appropriate service and supplies to patients.
- Develops a bereavement plan of care to address family member/care giver needs.
- Interprets and communicates pt/family faith and culture traditions. Identifies and communicates when spiritual/religious beliefs may impact the physical and psychosocial care provided by other team members.
- Documents recert and discharge assessments which accurately reflect change in patients status and declines/improvements realized in comparison with initial assessment elements.
- Educates patient and family members in a manner that overcomes barriers; matches their learning capabilities and meets fundamental needs.
- Investigates and applies payer specific Commercial Hospice Benefits to optimize treatment opportunities.
- Visit notes and orders are completed and transmitted in a timely manner according to policy. Corrections to care plans are entered and transmitted according to time line.
- Documents psychosocial patient/family assessments, financial assessment and MSW interventions within patients' electronic medical record.
- Implements social work plan that results in: a) enhanced strength of family systems, b) patient/family/caregiver utilization of community resources, c) maximization of medical benefits, d) enhanced environment for care delivery, e) dignity for the dying patient, f) maximized patient/family coping skills, g) support for patient/family cultural beliefs and values. Evaluates effectiveness of social work plan of care and modifies intervention as indicated.
- Facilitates and supports patient decisions and communication of self-determined life care decisions.
- Provides care according to plan of care/orders. Develops social work plan of care in collaboration with IDT.
- Practices in a manner sensitive to the needs of patients and families. Daily practice and documentation are evidence of understanding of palliative/comfort philosophy and approach (versus aggressive/curative treatment).
- Identifies and responds to indicators of imminent death, addresses patient/family needs at time of death.
- Demonstrates understanding of Medicare Hospice Benefit including benefit eligibility, qualification for admission, election process, certification, recertification, transfer, non-recertification and revocation.
- Utilizes Memorial Funds appropriately and submits documentation in a timely manner according to policy.
- Demonstrates understanding of Medicare Home Care benefit including eligibility, qualification for admission and services available.
- Complete or assist and educate the patients/caregivers on advanced directives, including living will, HCPOA, and POLST forms.
- Assist with Transportation barriers
- Assistance with Referrals for lack of access to food, clothing, assistance with power bills
- Make referrals for help in the Home
- Assistance with Applications (Medicaid, Community Care, SSDI)
- Make Elder Abuse/Neglect Referrals
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Schools - Social Worker
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Schools - Social Worker
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Schools - Social Worker
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School Social Worker
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