Social Worker/LMSW-CC

Northern Light Home Care and Hospice

Department : Home Health - Ellsworth

Position is located : Northern Light Home Care and Hospice Ellsworth

Work Type : Full Time

Hours Per Week : 36.00

Work Schedule : 8 : 00 AM to 5 : 00 PM

Summary :

The Licensed Master Social Worker functions within their scope of practice as a member of a multidisciplinary team, including the patient / family, physicians, nurses, pastoral care, hospice services, care management, and therapists in the Palliative Care Program. The Licensed Master Social Worker serves as patient advocate and liaison between the hospital, facility and community providers, resources, and agencies, working collaboratively, to ensure seamless transitions across the continuum of care for patients and families. Additionally, the Licensed Master Social Worker supports initiatives focused on Community and Provider education, and preventing readmission when aligned with patients' goals of care. The Licensed Master Social Worker seeks to resolve psychosocial patient care issues, provide support and counseling for those with serious, life-limiting illness,( including bereavement and anticipatory guidance for dying patients), provide support with identification of goals of care and decision-making, and assists in developing complex patient transition / discharge plans as needed. The Licensed Master Social Worker also provides assistance to patients, families and others with a wide variety of needs to include, but not limited to, financial concerns and / or emotional problems related to the impact of illness and disease burden. Provides supportive counseling to patients regarding adjustments to illness as well as other psychosocial needs as indicated. The incumbent performs duties and tasks in accordance with performance standards established for the job. The incumbent is responsible for participation in and completion of all patient safety initiatives appropriate to the position. In addition, the incumbent conducts all job responsibilities according to the Mission and Values of Home Care & Hospice / EMHS.

Responsibilities :

Clinical Practice- Works in conjunction with providers and others to assess, plan and initiate patient plan of care for patients with serious and life-limiting illness, including initial and ongoing Palliative Care consultations. Provides psychosocial assessments of the patients and families in relation to the crises of acute and chronic illness.

• Initiates a systematic, accurate and ongoing comprehensive assessment of needs of the client, family, and / or significant other.
• Meets with patients and families to provide psychosocial support and address goals of care.
• Obtains, interprets, and communicates necessary information regarding patients and families, including social history information, to Palliative Care team, and physicians.
• Arranges and participates in care conferences with appropriate patient care staff, including but not limited to Palliative Care, Hospice, Home health, Beacon, PCP / specialty practices, in-patient staff (Hospital / SNF / LTC) and patients and families.
• Consults with patients to determine psychosocial concerns and clarify goals of care.
• Meets with family to explore caregiving concerns.
• Reviews medical records / nurse assessment forms for further insight into patients' needs.
• Demonstrates competency in the fundamentals of case management.
• Develops and implements appropriate treatment plans and interventions in collaboration with primary, referring providers.
• Utilizes crisis interventions to mobilize resources in response to crises.
• Counsels and supports individual, families to help adjust and cope with illness.
• Make referrals to appropriate community resources.
• Initiates actions directed toward achieving expected outcomes.
• Collaborates with others to evaluate and modify the POC based on client outcomes.
• Exercises independent judgment in supervising and directing client care provided by other members of the client care team, with accountability if such care is not rendered accurately or appropriately.
• Adheres to discipline specific clinical practice standards.
• Acknowledges the value of and participates in the interdisciplinary team meetings and utilizes services according to standards of care.
• Provides service and produces work at or above expected levels of quality and consistent with agency defined quantitative standards.
• Documents accurately, completely and in accordance with Agency policy.
• Demonstrates knowledge, skills, and abilities necessary to provide care to the age groups served. Community Outreach- Serves as a resource to physicians and in-patient personnel regarding available agency, facility, and community services to assist in planning for Palliative Care patients and provision of ongoing education and support.
• Develops and maintains good working relationships with outside community health and social agencies. Works as a member of the Palliative Care service line in reaching out to the community to develop new resources for meeting patient needs.
• Participates in the provision of outreach education to Providers, community members, and others as directed as part of the EMHS Palliative Care service line.

Other Information :

Current license to drive in the state of Maine, with reliable transportation and agency required auto liability insurance. Must be able to travel within assigned region, or statewide, depending on the position.

Competencies and Skills

Credentials

Working Conditions