Social Worker II-MSW - Family Medicine - MOB 235 - Full Time - Days
- Req #: 10604
- Address: 2123 Auburn Ave
- City, State: Cincinnati, OH
- Zip: 45219
- Type: Full time
- Shift: Day
Job Description
Palliative care is specialized, interdisciplinary medical care for patients with serious illness and their families that is focused on relief from the pain, symptoms, and psychosocial stresses of advancing disease. The Palliative Care Social Worker provides comprehensive psychosocial assessment and directive intervention around symptom management, clarifying goals of care, guided decision-making, anticipatory grief, and (when appropriate) transitioning to hospice. The Palliative Care Social Worker role requires a highly specialized skill set to synthesize medical knowledge with social work expertise to ensure that the patient/family goals are clearly understood, aligned with the medical treatments offered, and consistent with a safe and supportive discharge plan for a highly complex patient population.
Responsibilities
Assessment:
• Assesses patients' evolving medical situation from a psychosocial framework, including functional status, goals of care and community support needs as it relates to discharge planning.
• Assesses family structure, dynamics, and decision-making preferences, including identification of a surrogate decision maker, need for advance care planning and/or family care conference.
• Assesses families for caregiver strain/burnout, anticipatory grief.
• Assesses patient/family environmental risk factors, patient/family/community support systems, age-related/developmental issues, financial barriers, health literacy, and chemical dependency/mental illness.
Documentation:
• Documents psychosocial assessment, care plan, ongoing progress notes, continuity of care, PASRR/HENS, level of care, discharge report, medical necessity for transportation, Medicare rights, and other needed documents related to patient/family care needs.
• Documents family care conferences, advance care planning decisions, utilizing the Medical Orders for Life Sustaining Treatment form, when appropriate, to ensure continuity of goals of care across settings.
Implementation/Care Coordination:
• Collaborates with the physician, primary unit nurse, case manager, community agencies, community hospice and palliative care agencies, patient, family, and significant others to develop future goals of care & immediate plan of care.
• Communicates with other hospital and community social workers to coordinate the patient's care needs.
• Facilitates family meetings with patients/families, physicians, and other members of the hospital's multi-disciplinary team.
• Provides and facilitates Advance Care Planning discussion related to areas such as code status, advanced directives, and anticipatory guidance for end of life planning.
• Provides psychosocial counseling and other therapeutic interventions for patient/family for issues that are common at end of life, including anticipatory grief, coping with physical and emotional suffering,
• Provides of bereavement care and outpatient resources for families/loved ones.
• Provides information and referral to families/loved ones regarding disposition of bodies post hospital.
• Acts as liaison between palliative care team and community palliative care agencies, community hospices, private duty agencies, sub acute rehabilitation, assisted living, intermediate care, and skilled care facilities.
• Ensures smooth transition from hospital setting via extensive communication with multiple key staff in discharge setting, along with financial coordinators.
• Utilizes broad knowledge base of multi-county, multi-faceted, community resources within and out of state to ensure patient/family needs are met.
• Provides education and crisis management for patient/family.
Leadership:
• Provides ongoing education and training around palliative care issues with a wide array of learners in multiple professional disciplines.
• Development delivery of appropriate educational initiatives within the hospital or in other settings in the community.
• Participates in palliative care improvement initiatives.
Professional Development:
• Attendance at social work continuing education opportunities, both local and regional, focusing on palliative care, ethics, and end of life.
• Assure ongoing licensure through the State of Ohio Counselor, Social Worker, and Marriage and Family Therapist Board.
• Procure palliative care specialty certification when eligible and maintain certification status.
Qualifications
KNOWLEDGE AND SKILLS:
Exceptional skill interviewing patients and families in crisis and individuals with a wide range of physical and emotional problems. Ability to prioritize many simultaneous demands. Medical and psychiatric competence including knowledge of health policy, regulations, and legislation and community resources. Strong knowledge of end of life issues and psych-social issues surrounding serious illness and death/dying. Self-awareness, professionalism, and good judgment in dealing with emotional and confidential issues. Excellent verbal and written communication. Skill in social work assessment and treatment modalities necessary to assess and treat individuals, families and groups. Ability to integrate social work philosophy and ethics into professional practice.
EDUCATION:
Master's degree in social work required.
LSW/LISW required.
YEARS OF EXPERIENCE: 2 years clinical experience in hospital, long-term care or hospice setting preferred.
LICENSES & CERTIFICATIONS:
• Advanced hospice and palliative care specialty certification (ACHP-SW) through the National Association of Social Workers preferred
• Assure ongoing licensure through the State of Ohio Counselor, Social Worker, and Marriage and Family Therapist Board preferred
Palliative care is specialized, interdisciplinary medical care for patients with serious illness and their families that is focused on relief from the pain, symptoms, and psychosocial stresses of advancing disease. The Palliative Care Social Worker provides comprehensive psychosocial assessment and directive intervention around symptom management, clarifying goals of care, guided decision-making, anticipatory grief, and (when appropriate) transitioning to hospice. The Palliative Care Social Worker role requires a highly specialized skill set to synthesize medical knowledge with social work expertise to ensure that the patient/family goals are clearly understood, aligned with the medical treatments offered, and consistent with a safe and supportive discharge plan for a highly complex patient population.
Responsibilities
Assessment:
• Assesses patients' evolving medical situation from a psychosocial framework, including functional status, goals of care and community support needs as it relates to discharge planning.
• Assesses family structure, dynamics, and decision-making preferences, including identification of a surrogate decision maker, need for advance care planning and/or family care conference.
• Assesses families for caregiver strain/burnout, anticipatory grief.
• Assesses patient/family environmental risk factors, patient/family/community support systems, age-related/developmental issues, financial barriers, health literacy, and chemical dependency/mental illness.
Documentation:
• Documents psychosocial assessment, care plan, ongoing progress notes, continuity of care, PASRR/HENS, level of care, discharge report, medical necessity for transportation, Medicare rights, and other needed documents related to patient/family care needs.
• Documents family care conferences, advance care planning decisions, utilizing the Medical Orders for Life Sustaining Treatment form, when appropriate, to ensure continuity of goals of care across settings.
Implementation/Care Coordination:
• Collaborates with the physician, primary unit nurse, case manager, community agencies, community hospice and palliative care agencies, patient, family, and significant others to develop future goals of care & immediate plan of care.
• Communicates with other hospital and community social workers to coordinate the patient's care needs.
• Facilitates family meetings with patients/families, physicians, and other members of the hospital's multi-disciplinary team.
• Provides and facilitates Advance Care Planning discussion related to areas such as code status, advanced directives, and anticipatory guidance for end of life planning.
• Provides psychosocial counseling and other therapeutic interventions for patient/family for issues that are common at end of life, including anticipatory grief, coping with physical and emotional suffering,
• Provides of bereavement care and outpatient resources for families/loved ones.
• Provides information and referral to families/loved ones regarding disposition of bodies post hospital.
• Acts as liaison between palliative care team and community palliative care agencies, community hospices, private duty agencies, sub acute rehabilitation, assisted living, intermediate care, and skilled care facilities.
• Ensures smooth transition from hospital setting via extensive communication with multiple key staff in discharge setting, along with financial coordinators.
• Utilizes broad knowledge base of multi-county, multi-faceted, community resources within and out of state to ensure patient/family needs are met.
• Provides education and crisis management for patient/family.
Leadership:
• Provides ongoing education and training around palliative care issues with a wide array of learners in multiple professional disciplines.
• Development delivery of appropriate educational initiatives within the hospital or in other settings in the community.
• Participates in palliative care improvement initiatives.
Professional Development:
• Attendance at social work continuing education opportunities, both local and regional, focusing on palliative care, ethics, and end of life.
• Assure ongoing licensure through the State of Ohio Counselor, Social Worker, and Marriage and Family Therapist Board.
• Procure palliative care specialty certification when eligible and maintain certification status.
Qualifications
KNOWLEDGE AND SKILLS:
Exceptional skill interviewing patients and families in crisis and individuals with a wide range of physical and emotional problems. Ability to prioritize many simultaneous demands. Medical and psychiatric competence including knowledge of health policy, regulations, and legislation and community resources. Strong knowledge of end of life issues and psych-social issues surrounding serious illness and death/dying. Self-awareness, professionalism, and good judgment in dealing with emotional and confidential issues. Excellent verbal and written communication. Skill in social work assessment and treatment modalities necessary to assess and treat individuals, families and groups. Ability to integrate social work philosophy and ethics into professional practice.
EDUCATION:
Master's degree in social work required.
LSW/LISW required.
YEARS OF EXPERIENCE: 2 years clinical experience in hospital, long-term care or hospice setting preferred.
LICENSES & CERTIFICATIONS:
• Advanced hospice and palliative care specialty certification (ACHP-SW) through the National Association of Social Workers preferred
• Assure ongoing licensure through the State of Ohio Counselor, Social Worker, and Marriage and Family Therapist Board preferred
