Hospice LCSW

Waveny LifeCare Network•Wilton, CT

18d

About The Position

The Hospice LCSW provides social work services to hospice patients and families under the direction of a physician and in accordance with the physician and interdisciplinary group (IDG) plan of care. The role includes timely visits, psychosocial assessments and reassessments, counseling and crisis intervention, care planning, patient and family education, coordination with the IDG, and support through the end of life and bereavement-related needs. The social worker respects patient wishes and preferences and supports a palliative focus of care. The position assesses the effects of terminal illness on patients and caregivers, including physical, functional, psychosocial, environmental, and daily-living needs. It evaluates family dynamics, communication, caregiver capacity, support systems, cultural needs, risk factors, coping, and responses to interventions. Services may include advance-directive preparation, long-term-care planning, funeral planning, and help with fiscal, legal, and health care decision-making transitions, as well as referrals to hospice, home health, and community resources. The LCSW documents assessments, plans, visits, progress, interventions, and communications in the agency EMR. Assessment documentation and visit documentation are due within 24 hours; ten-day, sixty-day, and discharge summaries must also be completed timely. The role participates in case conferences, case management, IDG meetings, and other team meetings.

Responsibilities

Accept referrals and make timely visits in accordance with licensure and accreditation requirements and under the direction of a physician and the physician/IDG plan of care.
Complete initial psychosocial assessments and reassessments; identify problems, interventions, visit schedules, strategies, and measurable treatment goals with patients and families while respecting patient wishes.
Work with the IDG to maintain a palliative focus of care, explain patient rights and care choices, support informed consent, and help families understand changes associated with end-stage disease.
Assess the impact of terminal illness on patients’ and caregivers’ physical, functional, psychosocial, and environmental needs and activities of daily living.
Provide social work services in consultation with the physician, hospice IDG, and other care team members, including assessment, short-term counseling, crisis intervention, advance-directive assistance, long-term-care planning, funeral planning, and support with transfers of fiscal, legal, and health care responsibilities.
Assess family dynamics, communication patterns, caregiver capacity, support systems, obstacles, risk factors, cultural needs, and risk for pathological grief; arrange bereavement referrals and follow-up as needed.
Help patients and families identify reconciliation and closure priorities, promote acceptance of patients’ strengths and qualities, and adjust support according to patient preferences as death approaches.
Evaluate patient and family responses to psychosocial interventions and patient progress; coordinate plans and participate in developing or revising the plan of care and visit frequency with the IDG, patient, family, physician, and other participants.
Instruct patients, families, and relevant members of the patient care team about the treatment regime when indicated.
Provide appropriate community resources and identify needs for other hospice or home health services and make referrals when needed.
Assist with preparation and support for the patient’s death.
Document psychosocial assessments, plans, visits, progress, interventions, education, client responses, and communications in the agency EMR; complete visit documentation and initial assessment documentation within 24 hours.
Report to the physician, IDG, and others as needed; complete ten-day, sixty-day, and discharge summaries in a timely manner.
Participate in case conferences, case management, IDG meetings, and other team meetings.