Job Summary

Hospice and palliative social workers have unique education, skills, and training essential to the interdisciplinary provision of holistic patient-centered care. Their psychosocial expertise and attention to the social determinants of health enables IDTs to better appreciate the complexity of issues patients and families face and thereby develop more effective, feasible, and patient-directed interventions.

Job Responsibilities

• Assess patient's mental status and capacity to participate in care plan (mini mental status exam may be an appropriate diagnostic tool)
• Assess patient and family emotional state, i.e. anxiety, depression, adjustment to illness, emotional and spiritual support needs.
• Provide counseling and psychotherapy for patients and families in crisis within the limits of inpatient care, including nonpharmacological symptom management strategies and coping skills.
• Provide anticipatory grief support to terminal patients & family members experiencing social, emotional, behavioral & psychiatric problems during end-of-life transition.
• Assess Patient and family living arrangements, support system, family structure and dynamics, and social history.
• Develop and document a treatment plan based on the assessment, incorporating counseling, advance care planning, and educational components as needed.
• Assist as liaison to promote discussion between the patient, family, and medical team, in order to facilitate understanding of the patient's medical condition and treatment options, and to establish clear, patient-centered goals of care and care plans.
• Guide elucidation of patient's wishes.
• Document reiteration of patient's condition, prognosis, and care plan options in terms appropriate to patient and family's cultural and educational background;
• Document education, completion and implementation of advance directives, including health care proxy, living will, POLST forms, code status orders
• Clarify patient and family's desired direction for care, including comfort-based care and guidance with funeral planning.
• Provide education and guidance to the patient, family and care team members pertaining to hospice and palliative care.
• Document reiteration of disease processes, prognosis, and associated risks and benefits of treatment options
• Clarify palliative care philosophy and care options, including inpatient and community-based palliative care and hospice care.
• Assist with processes and procedures related to withdrawal of care, end-of-life care, and patient's death.
• Provide psychosocial education to patients, family caregivers, hospital service providers and outside communities as appropriate about hospice and palliative care philosophy. Deliver educational modules relating to palliative care social work to Fellows, Residents, Medical Students and other learners during the course of their clinical rotations.
• Collaborate with the larger Palliative Care Team, communicating clearly and effectively with other team members to provide quality patient and family care, meet individual patient and family members care needs, and achieve appropriate palliative care plans.
• Attend and contribute to administrative team meetings.
• Participate in and contribute to weekly team rounds.
• Mediate conflict within and between families, interdisciplinary healthcare providers, and service organizations.
• Collaborate with other team members, to act as a liaison between the Palliative care team, Bioethics team, the Office of the Medical Director, consult teams and the primary medical team.
• Coordinate with unit social workers to assure optimal planning for discharge for patients and families to navigate the complexity of the healthcare system .
• Advise If a PCSW consultation is requested and the patient and family opt for a palliative care plan, recommendations for care plan and disposition with appropriate documentation, and will remain available to unit SW, team, patient and family for ongoing consultation.

Requirements:

• Master's Degree in Social Work
• Four (4) or more years job related experience including children and families in a direct clinical/therapeutic capacity.
• Basic Life Support (BLS)
• Licensed Medical Social Worker (LMSW)

Preferred:

• Minimum of two years experience in hospice and palliative medicine
• Minimum of two years experience in hospice and palliative medicine
• Licensed Clinical Social Worker (LCSW)