The Social Worker is an experienced professional and member of the patient care team who provides emotional and practical support for patients and their families in accordance with their unique Plan of Care. As part of the patient care team the Social Worker meets with patients and their families, coordinates with the clinical team and connects them with community resources and services.

Essential Functions and Skills

Patient Care

• Assesses the psychosocial status of patients and families/caregivers related to the patient's terminal illness and environment and communicates findings to the Registered Nurse and other members of the interdisciplinary care team. Provides an assessment in the patient's identified residence and assistance when this is not safe and another plan is required.
• Carries out social evaluations, including family dynamics, caregiver abilities, communication patterns, suicide risk, neglect, or abuse, and plans intervention based on evaluation findings.
• Counsels' patient and family/caregivers as needed in relationship to stress, and other identified coping difficulties. Provides crisis intervention when necessary.
• Provides ongoing Bereavement support to individuals identified as moderate or high-risk.
• Assesses any special needs related to the culture of the patient and family while educating interdisciplinary care team. Includes communication, role of family, space, and any special traditions or cultural considerations.
• Works under the supervision of Masters Prepared Social Worker (MSW).
• Maintains clinical records on all patients referred to social work.
• Educates patients and families and assists in preparation of advanced directives.
• Provides information and referral services for patients and families/caregivers regarding practical and environmental needs.
• Provides information to patients and families/caregivers regarding and serves as a liaison to community agencies.
• Maintains and develops contracts with public and private agencies as resources for patients and personnel.
• Participates in the development of the individualized plan of care, involving the patient and family, and attends regularly scheduled interdisciplinary group meetings, assisting the team in recognizing the effects of the psychosocial stresses on the symptoms of the terminal illness.
• Assists physician and other team members in understanding significant social and emotional factors related to health problems and death/dying issues.
• Assists Bereavement leadership in maintaining a program to meet the needs of families/caregivers for 13 months following the death of a patient to ensure compliance with all state, federal, and CHAP regulatory requirements.
• Ensures the initial bereavement assessment is completed or assigned to appropriate team member in a timely manner.
• Assists Chaplain in making condolence call to bereaved as needed.
• Assists with maintaining, organizing, and updating bereavement support group schedule.
• Assists family and patient in planning funeral arrangements, financial, legal, and health care decision responsibilities.
• Responsible for maintaining compliance with all HIPAA regulations and requirements. Treats all patient information as confidential and utilizes protected health information on a minimum necessary basis.