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About the Role

The Social Worker coordinates and provides medical social services to patients and families in various hospice, residential, and hospital settings. Services are provided under the direction of a hospice physician, in conjunction 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 the notes and 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, divergent expectations, coping and the need for counseling and support.
• Assesses the existing emotional and social support systems and the need for additional support.
• Assesses need for volunteer support.
• Identifies the developmental level of patient/caregiver, obstacles for learning or ability to participate in care and assists with understanding of goals and interventions.
• Assesses caregiver’s ability to function and provide care, communication abilities, environmental resources and obstacles to maintaining patient safety.
• Assesses the potential risk for suicide and for abuse, neglect or exploitation.
• Assesses quality of life and sense of well-being and the loss of ability to enjoy physical activities and when appropriate, intimate issues.
• Assesses needs related to cultural values and preferences including communication, space, role of family members and special traditions that impact delivery of care and end of life practices.
• Identifies family dynamics and communication patterns including, change in family roles, mental illness and substance abuse issues.
• Assesses the understanding of the diagnosis/prognosis, access to adequate and accurate information and the desire for information and education.
• Evaluates the need for additional resources, respite care or long term care, including the ability to accept the change in level of care and identifies resources and assists with placement.
• Identifies and determines eligibility for community resources, assesses patient/caregiver ability to access them, make referrals and liaisons with community service providers.
• Assesses need for end-of-life decision making and assists with completion of advance directives and final arrangements as requested.
• Assesses financial concerns and assists with accessing financial resources as needed.
• Assesses the caregiver’s risk level for complicated or pathological grief and the need for bereavement support and early intervention.
• Provides support through education and strength-based counseling, crisis intervention, advocacy and mediation/facilitation for end-of-life stressors related to caregiving and death and dying to help manage anxiety, depression and to normalize emotions.
• Evaluates response to psychosocial interventions and satisfaction of services provided.
• Assists members of the IDT in recognizing and understanding the social, emotional, mental stress or disorder that may exacerbate symptoms related to terminal illness.
• May refer to the DSM V as a tool to understand a diagnosis and provide education about the impact of mental illness at end-of-life and how to communicate with the patient and caregiver.
• Facilitates and participates in IDT meetings and other patient care conferences as needed.
• Communicates psychosocial information to inpatient facilities and across care teams when level of care or location is changed to ensure continuity of care.
• Participates in coordination of discharge planning and referrals as needed.
• Evaluates own need for support and self-care, using identified systems to meet needs.
• Recognizes and maintains professional boundaries in relationships with patient/caregiver.
• Abides by minimum expectations for on call rotation.
• Performs POS documentation and completes/signs all documentation according to agency protocol.
• Complies with minimum weekly visits and minimum patient care hours requirements per company protocol.
• Other duties as assigned.

Requirements

• One year experience in a healthcare environment (including volunteer or intern experience).
• Experience in hospice, home-health, or hospital social work (Preferred).

Skills

• Psychosocial assessments
• Client family counseling related to end of life and other co-occurring mental health disorders
• Family mediation
• Establishing treatment plans to address symptomatology
• Offering assistance with community resources
• Strength-based counseling
• Crisis intervention
• Advocacy
• Mediation/facilitation for end-of-life stressors
• Communication
• Documentation

Location

• Spicewood - Austin, TX 78759

Work Type

• PRN
• After hours

Experience Level

• One year experience in a healthcare environment
• Experience in hospice, home-health, or hospital social work (Preferred)

Education Level

• Master of Social Work (MSW) degree from a school of social work accredited by the Council on Social Work Education.
• Licensed Master Social Worker (LMSW), with an unrestricted license in the State of Texas.