Social Worker-Admissions, Hospital Based (Per Diem- as needed, Days)

Your Career at Hospice…

Hospice & Community Care provides quality care to thousands of patients and families every year so they can live better at end of life. We are able to support hundreds of individuals in our community each day because of our incredible staff. Whether in a clinical role or supporting the organization behind the scenes, your career at Hospice & Community Care makes a meaningful difference to patients and families.

Social Worker- Admissions department

Mostly hospital based

PRN/Per Diem (as needed)

Day Shift (8am - 5pm or 9am - 6pm)

* Full Time orientation is 8am - 5pm for 5-6 weeks. 

JOB SUMMARY:

The social worker facilitates effective referral coordination and information exchange with the Interdisciplinary Team (IDT), prospective and current hospital-based general inpatient (GIP) patients, their caregivers, and hospital and community teams.

Provides explanations about the hospice benefit and organization services in a manner consistent with the patient and family level of understanding.

Records information necessary to assist the hospice physician in determining eligibility, plans and coordinates discharge needs for the prospective patient, and collaborates with community senior living community staff and hospice teams to facilitate a safe and effective discharge plan.

Utilizes SW interventions, education, counseling, and support services to address the identified psychosocial needs of patients and caregivers. 

ESSENTIAL FUNCTIONS:

• Collaborates with hospital providers and staff IDT to develop a plan of care, complete initial and ongoing comprehensive assessments, and plan/evaluate SW interventions.
• Conducts admission assessments/information visits and follow-ups on hospitalized patients 
• Conducts high-risk admission assessments/follow-ups in hospitals where psychosocial issues are present, including but not limited to patients living alone, inadequate caregiving/decision-maker situations, and significant mental health/substance abuse concerns.
• Documents in accurately and concisely at the time the service is provided.
• Initiates, coordinates, and revises the plan of care on an ongoing basis with input from the IDT, patient, caregiver, hospital providers, and staff.
• Participates in hospital discharge planning, when needed, collaborating with hospital case management on the plan. 
• Participates in IDT meetings to report on the plan and update the comprehensive assessment.
• Provides education and support to patients and caregivers regarding diagnosis, care, treatments, medications, and end-of-life expectations in a method or manner that they understand.
• Provides education and support to hospital staff.  
• Supports special needs of patients and families including the pinning of Veteran patients through the We Honor Veterans program.
• Communicates effectively with organizational staff, physicians, patients, families, hospital staff, outside contractors, and community agencies.
• Anticipates, assesses, and responds to pain and other symptoms of physical, emotional, and spiritual suffering.
• Works in collaboration with IDT members, managing the psychosocial care of assigned caseload.
• Identifies patient and caregiver stressors and strengths to direct interventions throughout the patient's illness, including initiating post-death bereavement support,
• Demonstrates proficiency in navigating systems, knowledge of community resources, advocacy, individual/group counseling, and rapport building,  
• Understands reimbursement and payer source implications to the plan of care and utilizes resources wisely and effectively.
• Assists with the orientation of new staff and visiting professionals.

QUALIFICATIONS:

• MSW required
• LSW or LCSW is also required or must be obtained within 2 years of hire date.
• Two years' experience in the health care setting preferred.

EOE