Hospice Travel Social Worker
How You’ll Make a Difference (Essential Functions)
Travel Resource SW is responsible for patient and family satisfaction through the provision of direct social work services by conducting assessments, providing interventions, creating and updating the plan of care, communicating, and documenting.
Travel within the Agrace geographic service area to meet with patients and families. Lead conversations with patients and families to convert appropriate referrals to admissions. Answer questions about Agrace values, services, benefits and philosophies. Overcome objections to enrolling in hospice or palliative care and create a sense of urgency with each referral.
Obtain informed consent for hospice services and complete Electronic Health Records (EHR) documentation. Complete insurance paperwork, DME orders, pharmacy service enrollment, etc. Provide required documentation and referral process information to healthcare facility partners, Health Information Management (HIM) Department and homecare team or inpatient unit.
Provide essential healthcare coverage and financial information to the Finance Department. Collaborate with discharge planners and hospital staff to ensure ease of transition from hospital. Assist with incoming referrals to Agrace services.
Facilitate follow-up and flow of information and legal documentation to admissions team and partners to support enrollment with Agrace. Schedule Agrace enrollments and consults. Provide scheduled and unscheduled informational visits and tours to potential patients and families.
Assist in training and providing shadow opportunities for internal and external partners when assigned.
Initial and Ongoing Patient/Family Assessments
Aim to assess patient and family psychosocial, spiritual, grief and educational needs as part of the initial and comprehensive as per the patient’s individualized Plan of Care (POC).
Advocate for patient/family goals. Coordinate transition planning in collaboration with the patient/family, homecare, and Interdisciplinary Team (IDT). Anticipate and respond to patient/family psychosocial, spiritual, resource, or grief needs. Round on patients.
Care Planning and Coordination
Collaborate with IDT and patient/family to formulate, implement, and revise individualized Plan of Care (POC) in the electronic health record (EHR). The POC includes goals, interventions, education, discharge plan, etc.
Read, understand, and follow POC. Document education, interventions, and outcomes in EHR. Intervene, document, and report significant changes in condition or unusual incidents to appropriate IDT member such as client abuse/neglect, suicidal intent, harmful coping mechanisms or violence, etc.
Facilitate communication among patients, families, and Agrace staff.
Education, Intervention, and Resources
Provide individual patient/family education and support regarding behaviors, emotions, and psychosocial adjustment to terminal illness, dying, and bereavement. Evaluate the effectiveness of education and adjust to meet needs.
Provide appropriate education and interventions for patient/family based on clinical assessment and patient/family goals. Evaluate the effectiveness of interventions and adjust to meet needs.
Develop and maintain knowledge of community, legal, Agrace, and hospice specific resources. Refer patients/families to resources. Act as patient/family advocate to obtain resources.
Assist with Power of Attorney for Health Care (POAHC), Financial Power of Attorney, Living Will, and Guardianship including assistance with POAHC capability and competency assessment.
Miscellaneous
Participate in meetings to plan and evaluate patient/family services. Participate in SW on-call rotation. Participate in education and outreach. Participate and complete volunteer competency visits annually.
Participate in death visits, including assistance with post-mortem cares using safe body mechanics. Precept new staff and students.
MSW may audit or oversee the work of BSW
About Agrace
For more than 45 years, Agrace has been an innovator and leader in both caring for patients and their families, and in educating others about death, dying and grief.
We are the largest hospice provider in Wisconsin. Well known for end-of-life care, Agrace also serves people across southern Wisconsin who are aging, seriously ill or grieving.
At Agrace we are strengthened by the unique experiences, cultures and traditions of our staff, patients and clients. Together, we pursue a vision in which every Agrace staff member is treated fairly, and every patient and client experiences the respectful, individualized care they need and deserve.
Agrace Health Inc. is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.