Social Worker
3 days ago
Social Worker - Advanced Illness Care
Job Summary:The Social Worker is responsible for delivering social work services to patients with advanced illnesses, including psychosocial evaluations, ongoing counseling, casework services, and coordination of referrals and transitions. The Social Worker provides support and care for patients in various settings, including their homes, assisted living residences, shelters, hospitals, emergency departments, skilled nursing facilities, clinics, and specialty settings.
Key Responsibilities:- Conduct comprehensive psychosocial assessments and make appropriate referrals to community resources.
- Collaborate with clinical and support staff regarding patient/family/caregiver issues.
- Provide patient and family counseling and education, considering family system/dynamics and coping methods.
- Help patients and families develop coping strategies to manage declining physical health and emotional or spiritual needs.
- Partner with patient providers and interdisciplinary care teams to facilitate care that meets individual needs, values, and preferences.
- Provide short-term crisis intervention and assume an active role as advocate for families.
- Assist clinicians and clinical teams with management of transitions of care when patients move from one setting to another.
- Provide direct patient care support in various settings, utilizing palliative care principles, trauma-informed care, motivational interviewing, and case management strategies.
- Participate as a member of interdisciplinary care teams, assisting with establishing and implementing psychosocial care plans for patients with serious, complex, and/or chronic illnesses.
- Assist patients and families with advance care planning, including discussions about goals of care/treatment, power-of-attorney documentation, the POLST form, and the Oregon Advanced Healthcare Directive Form.
- Communicate and coordinate with other providers to ensure care is coordinated and consistent with patients' goals of care, including AD/POLST.
- Assist with establishment of POA-HC (power of attorney for health care) and end-of-life care plans as needed.
- Provide education to patients, family members, caregivers, and Housecall Providers staff regarding mental health issues, grief, resiliency, hospice services, community resources, benefits, and entitlements.
- Provide consultation on ethical issues that arise for HCP staff.
- Conduct mental status exams (e.g., MMSE, SLUMS, MoCa) as requested by Providers.
- Provide advocacy for patients and families with various community agencies, care facilities, and other institutions as needed.
- Assist clinicians with organization and/or facilitation of care conferences for assessment, education, or conflict management.
- Masters degree in social work from an accredited college.
- Current Oregon LCSW, LMSW, or CSWA license.
- Minimum 1 year work experience in geriatrics, home health, hospice, hospital, primary care/specialty care clinic, or other community-based mental health or outreach social work.
- Valid drivers license, acceptable driving record, and automobile liability coverage or access to an insured vehicle.
- CPR certification at hire or within 6 months in position.
- Experience dealing with substance use disorders, care coordination, and needs assessment for high-risk populations.
This position requires travel outside of the workplace at least weekly, and the employee's personal vehicle may be used. Driving infractions will be monitored in accordance with organizational policy.
This position may occasionally require more than 8 hours per day.
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