Palliative Care Social Worker

About the Role

Provides social work services, assesses and enhances the patient's, family's, and significant other's ability to cope with physical, emotional, and environmental problems related to illness, convalescence, and discharge planning. Works collaboratively with the multidisciplinary healthcare team to establish a discharge plan for the patient.

Responsibilities

• Conducts psychosocial assessment/reassessment of patients and significant others relating to social, emotional, and cognitive capabilities in relationship to their illness and health maintenance needs.
• Develops and implements a plan of intervention addressing needs identified during assessment.
• Collaborates with the multidisciplinary team to ensure appropriate discharge planning.
• Provides counseling for patients, families, and significant others to assist with coping related to new diagnoses, chronic illness, palliative, or terminal care.
• Advocates on behalf of patients and families to enable them to obtain necessary services.
• Serves as a resource and provides counseling related to treatment decisions and end-of-life care issues.
• Refers patients and significant others to community-based services/resources to meet continuum of care needs.
• Coordinates team and/or family conferences to facilitate patient care progression.
• Provides psychosocial counseling and crisis interventions to patients and significant others.
• Provides interventions in cases involving child abuse/neglect, domestic violence, elder abuse, institutional abuse, guardianship, foster care, adoption, psychiatric assessment and placement, Advance Directives, trauma, and substance abuse.
• Facilitates completion of placement-related documentation, including nursing home grants and applications.
• Completes referrals to options programs where appropriate.
• Documents in accordance with hospital and departmental requirements.
• Works with Case Managers to provide discharge planning services per departmental policies and procedures in collaboration with the multidisciplinary team and patient/family.
• Identifies patients and locates family and/or next of kin.
• Educates patients and significant others on obtaining health insurance and provides necessary documents for welfare insurance applications.
• Initiates or ensures medical assistance applications are completed in a timely manner.
• Follows up with external services regarding applications.
• Provides psychosocial assessment, intervention, and updates in the electronic medical record throughout hospitalization, discharge planning, and relevant post-acute care.
• Supervises field placement of MSW students.
• Refers cases to the Placement Official Social Worker to assist in obtaining placement for patient discharge when appropriate.
• Precepts and mentors new staff members.
• Facilitates and coordinates discharge plans for patients leaving on weekends, including homecare/hospice services, transportation, and post-acute facility placements.
• Performs assessments and develops interventions specifically for trauma patients.
• Obtains relevant post-acute authorizations.
• Manages Livanta appeal determinations and addresses alternate discharge plans if necessary.
• Provides updates to post-acute facility liaisons regarding possible weekend discharges.
• Reviews discharge orders to determine patient transitions to the next level of care.
• Assists with completing relevant 302 paperwork when necessary.
• Documents updates for weekday staff per department procedures.

Requirements

• Master’s Degree from an accredited Masters of Social Work program required.
• 2 years of hospital-based social work experience.

Skills

• Knowledge of medical terminology and disease processes.
• Knowledge of community resources and insurance regulations.
• Ability to work with multidisciplinary teams, outside resources, patients, families, and significant others.
• Ability to establish an appropriate plan to safely discharge patients to the next level of care.

Physical Demands

• Lift and carry up to 25 lbs.
• Frequent sitting and standing.
• Frequent keyboard use.
• May be required to perform activities specific to the role, including kneeling, bending, squatting, and performing CPR.

Schedule

Workday Day shift.

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including:

• Medical (including prescription), supplemental insurance, dental, and vision coverage.
• Life and AD&D insurance.
• Short- and long-term disability.
• Flexible spending accounts.
• Retirement plans.
• Tuition assistance and discounts at Thomas Jefferson University after one year of full-time service or two years of part-time service.
• Voluntary benefits providing access to group rates on insurance and discounts.