Social Worker FT

DEPARTMENT Clinical Services REPORTS TO Social Work Supervisor SUPERVISES None POSITION SUMMARY The Social Worker is responsible for coordinates and provides medical social services to patients and families in various hospice, residential and hospital settings. Services are provided under the direction of a hospice physician, in conjunction with an interdisciplinary team, and in accordance with an established plan of care. Responsibilities include: psychosocial assessments, client family counseling related to end of life and other co-occurring mental health disorders, family mediation, establishing treatment plans to address symptomatology, and offering assistance with community resources. DUTIES AND RESPONSIBILITIES Completes and documents the comprehensive initial psychosocial assessment according to agency policy and timeframe. Assesses ongoing needs throughout the course of care and documents in the notes and Plan of Care. Develops the plan of care and frequency of contact in collaboration with the patient and caregiver based on their goals for care and identified needs. Assesses psychosocial status, emotional factors related to terminal illness, divergent expectations, coping and the need for counseling and support. Assesses the existing emotional and social support systems and the need for additional support. Assesses need for volunteer support. Identifies the developmental level of patient/caregiver, obstacles for learning or ability to participate in care and assists with understanding of goals and interventions. Assesses caregiver’s ability to function and provide care, communication abilities, environmental resources and obstacles to maintaining patient safety. Assesses the potential risk for suicide and for abuse, neglect or exploitation. Finding of risk results in planned interventions according to agency policy. Assess quality of life and sense of well-being and the loss of ability to enjoy physical activities and when appropriate, intimate issues. Assesses needs related to cultural values and preferences including communication, space, role of family members and special traditions that impact delivery of care and end of life practices. Identifies family dynamics and communication patterns including, change in family roles, mental illness and substance abuse issues. Assesses the understanding of the diagnosis/prognosis, access to adequate and accurate information and the desire for information and education. Evaluates the need for additional resources, respite care or long‑term care, including the ability to accept the change in level of care and identifies resources and assists with placement. Identifies and determines eligibility for community resources, assesses patient/caregiver ability to access them, make referrals and liaisons with community service providers. Assesses need for end‑of‑life decision making and assists with completion of advance directives and final arrangements as requested. Assesses financial concerns and assists with accessing financial resources as needed. Assesses the caregiver’s risk level for complicated or pathological grief and the need for bereavement support and early intervention. Provides support through education and strength‑based counseling, crisis intervention, advocacy and mediation/facilitation for end‑of‑life stressors related to caregiving and death and dying to help manage anxiety, depression and to normalize emotions. Evaluates response to psychosocial interventions and satisfaction of services provided. Assists members of the IDT in recognizing and understanding the social, emotional, mental stress or disorder that may exacerbate symptoms related to terminal illness. May refer to the DSM V as a tool to understand a diagnosis and provide education about the impact of mental illness at end‑of‑life and how to communicate with the patient and caregiver. Facilitates and participates in IDT meetings and other patient care conferences as needed. Communicates psychosocial information to inpatient facilities and across care teams when level of care or location is changed to ensure continuity of care. Participates in coordination of discharge planning and referrals as needed. Evaluates own need for support and self‑care, using identified systems to meet needs. Recognizes and maintains professional boundaries in relationships with patient/caregiver. Abides by minimum expectations for on call rotation. Performs POS documentation and completes/signs all documentation according to agency protocol. Complies with minimum weekly visits and minimum patient care hours requirements per company protocol. Other duties as assigned. #J-18808-Ljbffr