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Summary and Responsibilities:
A professional responsible for providing medical social services to home care and/or hospice clients under a plan of treatment; supports clinical care by providing direct patient assessment and intervention, as well as training and direction to clinical staff; includes assessment of needs and issues impacting patient recovery, safety and long term planning; collaborates and communicates with other clinical disciplines and community resources to address identified needs; provides short-term counseling services and tools to patients and families; delivers quality services in accordance with established agency policies and procedures; ensures compliance with federal, state, and local guidelines for all services; assures the quality and growth of the agency through effective promotion and administrative practices.
1. Assesses psychosocial and emotional status of assigned patient; identifies coping, self image, resource needs, and factors related to terminal illness
2. Assesses capacity of home caregivers, and safety of home settings to cope with and meet patient’s needs as well as bereavement needs for hospice patient families
3. Develops social work plan of care based on patient needs, physician orders, and in consultation and coordination with nursing and therapy staff and other members of the interdisciplinary hospice team
4. Delivers services in accordance with the approved plan of treatment and plan of care
5. Maintains awareness of community resources and maintains collaborative relationships with other agencies to assist patients in obtaining resources for financial, psychosocial and medical needs
6. Assists the patient and the caregiver in identifying and utilizing information and services from other community resources
7. Participates in the agency’s clinical record review, clinical outcomes and adverse event reviews and performance improvement projects
8. Prepares clinical notes clearly and completely and turns into office within 48 hours
9. Attends care conferences, IDT/IDG meetings, staff meetings and attends in-service education at least quarterly
10. Develops or participates in the development of a discharge plan when the patient is transferred to another agency or service or when the patient is discharged or dies
11. Acts as a consultant to agency staff to assist clinical team members to understand social and emotional factors affecting illness, recovery, long term planning and the social/mental stress that exacerbates the symptoms related to terminal illness
12. Assists with funeral planning issues and transfer of responsibilities regarding fiscal, legal, and health care decision for terminally ill patients
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Additional Salary Information: We offer competitive Salary and Full Benefits
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