Provides in-home services to our patients. Evaluates and develops a plan of care personalized to fit the patients psychosocial needs. Assesses the psychosocial status of patients and families, caregivers related to the patients terminal illness and environment, and communicates findings to the interdisciplinary care team.
Counsels patient and family caregivers as needed in relationship to stress and other identified coping difficulties. Provides crisis intervention when necessary.
Educates family caregivers on and assists in preparation of advanced directives. Assists family and patient in planning for funeral arrangements, financial, legal, and health care decision responsibilities.
Assesses any relationships of the patients medical and nursing therapy needs in the home setting, financial resources, and available community resources.
Observes documents and reports changes in the patients condition to the interdisciplinary care team and Clinical Manager.
Actively participates in quality assessment, performance improvement, QAPI teams, and activities.
Able to supervise, instruct the performance of the Social Work Assistant (BSW/LSW) to assure that all medical social services are provided to patients in compliance with company, government, and professional standards as applicable.
Maintains and submits documentation timely per company policy, including any case conferences, patient-physician community contacts, visit reports, and progress notes.