Hospice Care Social Worker needed for part-time (20 hr/week), temporary (without end date), hybrid position in Washington DC.
Provides social service counseling and guidance to facilitate the maximum function and coping capacity of each patient and involved caregiver while following all policies and protocols, in accordance with the interdisciplinary plan of care. Provide compassionate care, advocacy, and psychoeducation from diagnosis to death through bereavement.
Responsibilities
1. Assist the core members of the pre-hospice/hospice team in understanding significant social, spiritual, and emotional factors related to the patient's health, to establish a plan of care which fosters the personal worth, spiritual well-being, and human dignity of each patient
2. Participate as a member of the interdisciplinary team and in the development and review of the plan of carefor assigned patients
3. Assess the social, spiritual, and emotional needs/factors in order to estimate the patient's and involved caregiver's capacity and potential to cope with the problems of daily living and with the terminal diagnosis and illness 4. Help the patient, family, and involved caregiver to understand, accept and follow medical recommendations and provide services planned to assist in achieving the optimum social, spiritual, and health adjustment within their capacity and level of health literacy
5. Prepare the patient to deal with the changes and the family to support the patient including education on Advanced Directives
6. Utilize all available resources, such as family, hospice, and community agencies, to assist the patient and family to live better within the limitations of the illness
7. Support the bereavement program at the site level, including, but not limited to:
a. Completing bereavement calls and visits to offer counseling and support
b. Facilitating bereavement support groups in the community, including an annual memorial service; c. Participating in the?monthly bereavement committee meetings;
d. Keeping the bereavement binder up to date (with meeting minutes, sign-in sheets fromgroups/workshops, etc.)
8. Provide discharge planning related to change of level-of-care or community placement
9. Observe, record, and report social, spiritual, and emotional changes, documenting all services in patient'selectronic medical record
10. Will participate in the on-call rotation and provide after-hours coverage as specified by needs of the agency 11. Other duties as assigned
Inpatient Hospice Center (IPC)
12. Ensures patient smoothly transitions from one hospice level of care to another
13. Serves as a patient navigator and contact for patients during transition
14. Facilitates care meetings in collaboration with hospice physician, team manager, patient, and involved care giver to ensure smooth delivery of hospice services, care coordination, advanced care planning and counseling for withdrawal of medical interventions
15. Develops and maintains effective working relationships with care teams that generate superior clinical and business performance
Palliative Consult Service
16. Serves as an integral member of the healthcare team providing assessments, coordination, treatment planning, information and referral to community resources and other social work services to meet the complex needs of a patients and families in the hospital, home, and post-acute setting
17. Provide counseling for disease acceptance and understanding
18. Takes, reviews, evaluates and prioritizes written and oral referrals
19. Maintains documentation records and data collections across all clinical records including Hospice electronic medical record and the host hospital system
20. Serves as a liaison between patient and Hospice for maintaining positive relationship with Hospice and providing continuity of care
21. Ensures patient smoothly transitions from one area of care to another; serves as a patient navigator and contact for patients during transition
22. Coordinates/schedules the team interview/consult with the patient and involved care giver 23. Develops and maintains effective working relationships with care teams that generate superior clinical and business performance
Pre-Hospice
24. Assists the clinician in execution of the care plan in the area of psychosocial issues as needed, including routine and emergent visits as assigned
25. Telephonic, virtual and or face-to-face evaluation of patient's psychosocial status when needed 26. On-going evaluation of patients' social determinants of health
27. Education of the patient and family on how to proactively manage symptoms, as well as how to respond appropriately in times of crisis with an emphasis on utilizing palliative in-home support and other lower acuity interventions when appropriate
28. Gather information regarding appropriateness for other services to best meet patient needs 29. Facilitation of referrals to community resources, both formal and informal to address the patient's needs and as directed by the patient's care plans
30. Navigation support for patients as they manage the healthcare continuum, including maximizing insurance benefits to promote healthcare needs
31. At time of discharge, management of the transfer of patients from the pre-hospice program to the appropriate referral source, including to hospice or primary care providers
32. Collaborate with the rest of the team including alerting the team to changes and newly identified patients needs as they arise
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