Provides clinical psychosocial support to patient and family/caregiver in accordance with patient preferences, goals, and needs. The position works collaboratively with the Interdisciplinary Team/Group (IDT/IDG) as well as with facilities and agencies in the community.
Reports to the Clinical Manager or Director of Clinical Services.
Completes initial and on-going psychosocial and bereavement assessment of patient and family/caregiver to include the patient’s history, ethnic background, cultural and religious beliefs and the implications for the Plan of Care (POC).
Establishes goals based on assessment and mutual agreement with patient and family/caregiver. Serves as an additional primary contact for IDG/IDT collaboration and advocate for patient/family and other providers.
Identifies potential bereavement resources for patient and family/caregivers to assist in coping with loss, aging and death. Assesses and assists patients with advanced directives and care planning.
Evaluates patient/family psychosocial needs and individual/family counseling as part of the Plan of Care (POC). Delivers appropriate referrals to community resources such as financial assistance, legal aid, housing and/or education.
Communicates risk indicators to bereavement services as appropriate. Assists RN Case Manager with development of a comprehensive transfer and/or discharge plan in collaboration with patient, family, staff and referral agencies.
Utilizes knowledge of disease processes; skilled in assessing impact on patient and family dynamics and psychosocial wellbeing.
Other duties and responsibilities as assigned.
Supports the mission and values of hospice, palliative and home health care.
Provides patient care (neonates to geriatrics) as determined by the Plan of Care (POC) and in accordance with discipline. Utilizes critical thinking skills, education, mentoring, guidance and interventions to achieve goals of care.
Possesses knowledge of patient rights; ensuring an atmosphere which allows for the privacy, dignity and well-being of all patients in a safe and secure environment.
Understands the correlation between excellent patient care and the results of Hospice Item Set, CAHPS, SHPand/or other publicly-reported industry and/or accreditation quality benchmark programs.
Treats patients, family members and other clients with concern and empathy; respects their confidentiality and communicates in a courteous and respectful manner. Maintains and respects professional and personal boundaries. Adheres to HIPAA regulations and maintains confidentiality of all patients and families.
Meets National Association of Social Workers (NASW) Standards for Palliative & End of Life Care. Follows NASW Code of Ethics.
Works independently with minimum direction, anticipates and organizes workflow, prioritizes and follows through on responsibilities.
Attends team meetings and in-services on a regular basis. Participates in continuing education and professional development courses, to include annual education requirements as assigned to the discipline.
Works in a high volume environment with rapidly changing priorities.
Understands the importance of providing accurate and timely point-of-care documentation in Electronic Medical Record (EMR). Uses, clear concise and professional written and verbal communication.
Responsible for meeting visit frequency, case load and/or visits per shift requirements; takes on-call rotation as needed and/or assigned.
Possesses knowledge of necessary computer systems including Microsoft Office, Outlook and agency electronic medical records (EMR).
Promotes a holistic approach to patient care.
Cooperates with all co-workers; demonstrates flexibility to perform other duties as assigned.
Minimum Education: Master’s degree in social work from an accredited school of Social Work.
Minimum Experience: One (1) year of social work experience in a health care setting.
Required License: Current Colorado Social Worker license (LSW or LCSW) preferred. MSW must be willing to work towards licensure. Valid Colorado state driver’s license and proof of auto insurance.
Ability to lift/push/pull minimum of 30 lbs.
Prolonged, extensive, or considerable standing/walking/sitting
Manual dexterity and mobility
Visual and auditory acuity
May be exposed to infections and contagious diseases
Occasional exposure to radiation hazards
Occasional exposure to unpleasant patient or unit elements (sound, odor, sight, behavior)
Exposure to variety of electro-mechanical hazards
Subject to varying and unpredictable situations
Able to maintain job performance in emergency or crisis situation