This position is responsible for the delivery of social work services to Hospice patients and families, which includes the initial psychosocial assessment, ongoing psychosocial counseling, direct casework, bereavement services and community education, outreach and referral. Social Worker/Counselors are a core member of the Hospice Interdisciplinary team.
- Performs comprehensive initial and ongoing psychosocial assessments on referred patients/families including mental health status, sexuality, spirituality, risk and methods of coping.
- Assesses patient/family members for risk related to abuse/neglect and suicide and those with active or past substance abuse.
- Provides effective counseling approaches and processes for patients and families, including therapeutic and supportive interventions, patient/family life education, life review, crisis intervention and suicide prevention when indicated.
- Actively participates in the development and implementation of the Plan of Care, including patients and families with the most complex psychosocial needs.
- Utilizes the principles of case management in delivering effective services for a caseload of hospice patients and families.
- Conducts reassessments of patient/family needs and counseling as prescribed in the Interdisciplinary Team Plan of Care.
- Assesses and refers for ongoing bereavement services.
- Facilitates family support groups as needed.
- Responsible for end-of-life care planning including knowledge of DPOA, living wills, provision of care for dependents, assessing decision capacity, and funeral planning.
- Actively contributes psychosocial information at the Interdisciplinary Team meeting and interacts with other team members in a professional manner.
- Develops and maintains contact with appropriate community agencies and services in order to promote interagency cooperation and to facilitate related referrals.
- Responsible for discharge planning as prescribed in the Interdisciplinary Team Plan of Care.
- Documents comprehensive assessments, appropriate goals, interventions provided, and patient/family response to those interventions (obtained through direct patient/family contacts, telephone contacts and referrals) clearly and concisely for the patient medical record. Meets agency standards for clinical documentation.
- Maintains infection control practices as related to patient care activities.
- Maintains the standards of Social Work/Counselor in accordance with the principles set forth by the Ohio State Health Departments, NASW, Joint Commission, NHO, OHO and agency policies and procedures.
- Maintains productivity standards defined by the agency.
- Works with diverse cultures, life styles, children and adolescents, and acute and chronic mental illness, and substance abuse.
- Participates in the QAPI program, orientation, professional student education, and other activities as assigned.
- Participates in in-services or other continuing education to meet own needs and agency requirements.
- Responsible to learn and utilize technology made available by the agency to increase efficiency, communication and performance of duties.
- Attends staff meetings and completes all mandatory training.
- Holds in strictest confidence all patient information and discloses information and data only to persons authorized by Hospice.
- Performs other duties as assigned.
Social Worker/Counselors may have exposure to infectious diseases. This position will require driving to patient homes and facilities in various weather conditions and will be subject to day and/or night-time travel.