Social Worker - PRN Afterhours

About the Role

The Social Worker coordinates and provides medical social services to patients and families in hospice, residential, and hospital settings. Services are delivered under the direction of a hospice physician, in collaboration with an interdisciplinary team, and in accordance with an established plan of care.

Responsibilities

• Completes and documents the comprehensive initial psychosocial assessment according to agency policy and timeframe.
• Assesses ongoing needs throughout the course of care and documents in notes and the Plan of Care.
• Develops the plan of care and frequency of contact in collaboration with the patient and caregiver based on their goals for care and identified needs.
• Assesses psychosocial status, emotional factors related to terminal illness, coping mechanisms, and the need for counseling and support.
• Evaluates existing emotional and social support systems and the need for additional support, including volunteer assistance.
• Identifies the developmental level of patient/caregiver, obstacles to learning, and ability to participate in care.
• Assesses caregiver’s ability to function, provide care, communicate, and environmental resources impacting patient safety.
• Evaluates potential risk for suicide, abuse, neglect, or exploitation and implements planned interventions as per agency policy.
• Assesses quality of life, well-being, and loss of physical or intimate activities.
• Considers cultural values, preferences, and traditions that impact care delivery and end-of-life practices.
• Identifies family dynamics, communication patterns, mental illness, and substance abuse issues.
• Assesses understanding of diagnosis/prognosis, access to information, and desire for education.
• Evaluates the need for additional resources, respite care, or long-term care, including placement assistance.
• Identifies and determines eligibility for community resources, makes referrals, and liaises with service providers.
• Assesses need for end-of-life decision-making and assists with advance directives and final arrangements.
• Addresses financial concerns and assists with accessing financial resources.
• Evaluates caregiver’s risk for complicated grief and need for bereavement support.
• Provides support through education, strength-based counseling, crisis intervention, advocacy, and mediation for end-of-life stressors.
• Evaluates response to psychosocial interventions and patient/caregiver satisfaction.
• Assists the interdisciplinary team in recognizing social, emotional, or mental stress exacerbating terminal illness symptoms.
• Uses DSM V as a tool to understand diagnoses and educate about mental illness impact at end-of-life.
• Facilitates and participates in interdisciplinary team meetings and patient care conferences.
• Communicates psychosocial information across care teams during transitions in level or location of care.
• Participates in discharge planning and referrals as needed.
• Evaluates personal need for support and self-care, maintaining professional boundaries.
• Adheres to on-call rotation, documentation protocols, and minimum weekly visit/hour requirements.
• Performs other duties as assigned.