Hospice social Worker

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The Social Worker is an active member of the Capital Caring Health Interdisciplinary Team, providing a wide variety of direct and indirect social work services to patients/caregivers/families in accordance with the individualized plan of care, as prescribed by the physician. The Social Worker actively participates in coordination of all aspects of the patient's care, in accordance with current professional standards and practice. She/he participates in ongoing interdisciplinary comprehensive assessment; develops and evaluates the Plan of Care; contributes to patient and family counseling and education and participates in the QUAPI program and hospice sponsored in-service training.

Quality Provision of Services:
1. Develops an individualized plan of care with the patient/family, the physician, the nurse and other members of the interdisciplinary team to meet the patient/family psychosocial needs. Identifies problems, goals and interventions and revises them based on input and a reassessment every two weeks.
a. Involves the patient/family in the plan of care
b. Identifies and utilizes appropriate community resources
c. Assesses caregiver's ability to function adequately
d. Assesses need for counseling related to risk assessment for pathological grief
e. Assesses special needs related to cultural diversity including communication, space, role of family member and special traditions
f. Identifies the developmental level of patient/family and obstacles to learning or ability to participate in care of patient
g. Addresses patient/family questions and issues
h. Identifies obstacles to compliance and assists in understanding goals or interventions
i. Identifies support systems available to reduce stress and facilitate coping with end of life care
j. Evaluates for long term care when appropriate and assesses ability to accept change in level of care.
2. Under the direction of the Clinical Supervisor, accompanies the Admission Nurse on the admission visit to provide psychosocial assessment and support.
3. Functions as a member of the IDT, reporting changes in patient/family condition to appropriate members of the team, collaborating on care planning and coordinating provision of care.
4. Enhances the responsiveness of the environment and initiates appropriate referrals to other disciplines and/or community resources.
5. Assumes responsibility for own professional growth through continuing education, clinical supervision and participation in Social Work meetings.
6. Assesses at time of initial assessment the perceived bereavement risks of the patient's family and initiates a written plan of bereavement intervention that shall be incorporated into the patient's plan of care. The plan shall be based on the needs of the family and shall recognize the family's social, religious and cultural values.
7. Participates in committee work as approved by the appropriate supervisor.
8. Functions as a member of the office team by participating in office staff meetings and demonstrating flexibility in work schedules.
9. Participates and contributes to the Interdisciplinary Team through regular attendance at team meetings, active discussion to patient/family needs and individual consultation.
10. Participates in marketing/education in facilities as requested.
11. Participates in the QUAPI program and hospice sponsored in-service training.
12. Participates in the orientation of paid and volunteer staff.

Organizational/Regulatory Compliance:

1. Conducts a complete psychosocial assessment of the patient and family and participates in the development of the plan of care at the time of the patient's admission. Evaluates patient/family response to psychosocial interventions, including when there is a referral to community agency resources. Identifies family dynamics and communication patterns, patient/family psychosocial status, potential for risk of suicide and or abuse or neglect. Assesses environmental resources and obstacles to maintain safety.
2. Delivers or supervises the delivery of social services to the patient or the patient's family, including:
a. short-term individual counseling,
b. crisis intervention
c. assistance in providing information and preparation of advance directives
d. funeral planning issues and transfer of responsibilities regarding fiscal, legal and health care decisions
3. Reports any changes in the emotional, social or financial condition of the patient or family to the attending physician
4. Reviews and updates the plan of care as often as necessary
5. Assists the patient and family with identifying and accessing community resources. Assists the patient/family in assessing financial resources when appropriate.
6. Acts as consultant to hospice program staff.
7. Participates in the quality improvement reviews and evaluation of social services.
8. Obtains physician's orders for services, as necessary.
9. Prepares clinical and progress notes. Documents goal-directed counseling, interventions and responses, as well as telephone calls, referrals, etc. in a timely manner. Uses appropriate forms or formats according to Capital Caring Health policies and procedures.
10. Assesses bereavement needs. Completes interdisciplinary bereavement assessment within 7 days after the patient's death.
11. Participates in discharge planning. Develops or participates in development/implementation of live discharge plan, identifying patient/family needs when discharged.
a. Collaborates with the IDT to facilitate patients' transfer to or from another agency.
b. Assists patient/caregiver/family with transition.
c. Provides follow up contacts to determine success of transfer and offer alternatives as accepted by patient/caregiver/family.
12. Contributes to patient and family counseling and education.
13. For LONG TERM CARE: Follow the rules and regulation of the facility; documents per the "Documenting in Facilities" guidelines.

People/Communications:

1. Acts as a communication bridge between patient/family and the interdisciplinary team to facilitate understanding of the psychosocial needs and the plan of care. Communicates psychosocial information to inpatient facility when level of care is changed.
2. FOR LONG TERM CARE: Collaborates and communicates with the charge RN and/or RN caring for patient.
3. Assists survivors in transition to bereavement services and leads bereavement groups as need is identified.
4. Responds to emergencies with crisis interventions that may involve outside agencies such as Adult/Child Protective Service, Police, or Mental Health Mobile Crisis Unit according to Hospice procedures

Financial Stewardship

1. Achieves expected productivity standard (based on patient visits, coordination, and discharge planning) as defined by the organization and in alignment with best practices/the Capital Caring Health model.
The above statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

Supervisory Responsibilities:
N/A

Experience Requirements:

The Social Worker must have at least 2 years of master's level experience in an interdisciplinary health care setting.

Education Requirements:
The Social Worker must have at least a MSW from a Social Work Education accredited school.

Required Certificates and/or Licenses:
The Social Worker must have medical licensure from the governing body for practice for the District of Columbia, State of Maryland, and/or the Commonwealth of Virginia, if applicable.

Overall Skills:
The ability to demonstrate superlative oral and written communication skills as well as ability to organize and manage projects within defined timeframe and budget; work both independently and as part of a team; demonstrate excellent interpersonal and collaborative; demonstrate organizational skills with ability to delegate and follow up; manage multiple tasks and stressful situations with a positive attitude; demonstrate a strong work ethic and attention to detail; demonstrate skills in psychosocial assessment, crisis intervention and counseling; demonstrate knowledge of hospice-appropriate theories, e.g. general and family systems, object relations, transpersonal, and cognitive-behavioral, etc.; be an advocate for patient/family within the structure of the team, agency, medical setting, and community; conduct effective community education that enhances understanding of special needs of terminally ill; demonstrate sensitivity to issues of loss and grief.

Compensation Pay Range:

$ $40.00

This position requires consent to drug and/or alcohol testing after a conditional offer of employment is made, as well as on-going compliance with the Drug-Free Workplace Policy.

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