Social Worker (Hospice)
Posted on: July 21, 2021
The Home Services Social Worker identifies the psychosocial
needs of patients and families through assessment. Social work
interventions range from resource support identification and
acquisition (including community support, financial and
environmental enhancement) to short term counseling and emergent
crisis intervention. Social Services are provided as part of a
collaboration with interdisciplinary teams. Hours may vary
depending upon census and program need.
- Provide psychosocial assessments of patients and families to
identify emotional, social, and environmental strengths and
problems related to their diagnosis, illness, treatment, and/or
- Captures all legitimate revenue; conservative in expense and
resource use yet provides appropriate service and supplies to
- Develops a bereavement plan of care to address family
member/care giver needs.
- Interprets and communicates pt/family faith and culture
traditions. Identifies and communicates when spiritual/religious
beliefs may impact the physical and psychosocial care provided by
other team members.
- Documents recert and discharge assessments which accurately
reflect change in patients status and declines/improvements
realized in comparison with initial assessment elements.
- Educates patient and family members in a manner that overcomes
barriers; matches their learning capabilities and meets fundamental
- Investigates and applies payer specific Commercial Hospice
Benefits to optimize treatment opportunities.
- Visit notes and orders are completed and transmitted in a
timely manner according to policy. Corrections to care plans are
entered and transmitted according to time line.
- Documents psychosocial patient/family assessments, financial
assessment and MSW interventions within patients' electronic
- Implements social work plan that results in: a) enhanced
strength of family systems, b) patient/family/caregiver utilization
of community resources, c) maximization of medical benefits, d)
enhanced environment for care delivery, e) dignity for the dying
patient, f) maximized patient/family coping skills, g) support for
patient/family cultural beliefs and values. Evaluates effectiveness
of social work plan of care and modifies intervention as
- Facilitates and supports patient decisions and communication of
self-determined life care decisions.
- Provides care according to plan of care/orders. Develops social
work plan of care in collaboration with IDT.
- Practices in a manner sensitive to the needs of patients and
families. Daily practice and documentation are evidence of
understanding of palliative/comfort philosophy and approach (versus
- Identifies and responds to indicators of imminent death,
addresses patient/family needs at time of death.
- Demonstrates understanding of Medicare Hospice Benefit
including benefit eligibility, qualification for admission,
election process, certification, recertification, transfer,
non-recertification and revocation.
- Utilizes Memorial Funds appropriately and submits documentation
in a timely manner according to policy.
- Demonstrates understanding of Medicare Home Care benefit
including eligibility, qualification for admission and services
- Complete or assist and educate the patients/caregivers on
advanced directives, including living will, HCPOA, and POLST
- Assist with Transportation barriers
- Assistance with Referrals for lack of access to food, clothing,
assistance with power bills
- Make referrals for help in the Home
- Assistance with Applications (Medicaid, Community Care,
- Make Elder Abuse/Neglect Referrals
Keywords: CARLE, Champaign , Social Worker (Hospice), Other , Champaign, Illinois
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