Summary

The Home & Supportive Care Social Worker is accountable for psycho-social assessments and provision of medical social services for patients and their families, in accordance with an interdisciplinary plan of care. This is achieved through a collaborative interdisciplinary care delivery model which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual’s health needs. There will be a particular focus on symptom management, comfort, and quality of life treatment/care decisions through communication and available resources to promote quality, including Advanced Care Planning.

Essential Duties and Responsibilities

These duties and responsibilities described below represent the general tasks performed on a daily basis. Any other duties as needed to drive to the vision fulfill the mission and abide by the values of the organization.

• Involved in identifying patients for Supportive Care social work services through collaboration and communication with the interdisciplinary team and appropriately opens case for active social work needs.
• Provides counseling to patient/family to help facilitate adjustment to complex or serious illness.
• Provides consultation across care settings as needed, including inpatient, outpatient, and home.
• Facilitates effective interdisciplinary care planning and coordination through participation in Interdisciplinary Rounds and Case Conference huddles.
• Serves as a role model and mentor for clinical effectiveness initiatives within the Home & Supportive Care service line.
• Uses communication, negotiation, and conflict resolution skills to identify and resolve obstacles to timely treatment or timely transition to the appropriate level of care.
• Promotes clinical effectiveness through the identification of process barriers and system issues that impede transition to Home Health Care, Palliative Care, and/or Hospice Care. Initiates process improvement efforts using an interdisciplinary team approach.
• Assists in the development of process and outcome measurements to trend performance improvement over time.
• Responds in a timely manner to consults and referrals by documenting preliminary needs assessment and goals of care upon receipt of consult or referral.
• Interviews patients and family members to comprehensively assess the patient’s health status, risk factors, lifestyle choices, functional status, psychosocial status, person and community support systems, financial resources, goals of care and home environment conditions.
• Maintains active and ongoing communication with all stakeholders and assists with care transitions across the continuum as assigned.
• Bereavement – Assess risk and intervenes clinically to identify potential for complicated grief and explores anticipatory bereavement related to possible death along the continuum of illness. Provide coordination for the delivery of the service line’s bereavement services as assigned.
• Attend required hospital-wide orientations, meetings, and in-services
• Demonstrate a commitment to flexible work scheduling when necessary to ensure patient care

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience

Minimum Required Education: Master’s degree in social work from an accredited college or university.

Preferred Education: Licensure as a Licensed Clinical Social Worker (LCSW)

Experience: 1+ year as a Clinical Social Worker in a healthcare related area is preferred, however new graduates with a completed internship will also be considered.

Certificates, Licenses, Registrations

Must have and maintain current American Heart Association BLS Certification.