The social worker contracted or employed through the organization is responsible for the implementation of standards of care for medical social work services and for adherence to all conditions in the Service or Employment Agreement which include providing care based on the Social Work Practice Act. The social worker assesses the psychosocial status of patients and families/caregivers related to the patient's terminal illness and environment and communicates findings to the registered nurse and other members of the interdisciplinary group. They provide an assessment in the patient's identified residence and assistance when this is not safe and another plan is required. The role involves carrying out social evaluations, including family dynamics, caregiver abilities, communication patterns, high-risks for suicide, neglect or abuse and plans intervention based on evaluation findings. Counseling patients and families/caregivers as needed in relationship to stress, and other identified coping difficulties, and providing crisis intervention when necessary are key functions. The social worker also assesses for, and educates the interdisciplinary group on, any special needs related to the culture of the patient and family, including communication, role of family, space, and any special traditions or taboos. Maintaining clinical records on all patients referred to social work and preparing clinical and progress notes are essential. Educating patients and families on, and assisting in, preparation of advanced directives, and providing information and referral services for organization patients and families/caregivers regarding practical and environmental needs are also part of the role. The social worker serves as a liaison between patients and families/caregivers and community agencies, and maintains collaborative relationships with organization personnel to support patient care. They also maintain and develop contracts with public and private agencies as resources for patient and personnel. Participation in the development of the individualized plan of care, involving the patient and family, and attending regularly scheduled interdisciplinary group meetings, assisting the team in recognizing the effects of the psychosocial stresses on the symptoms of the terminal illness are important. Assisting the physician and other team members in understanding significant social and emotional factors related to health problems and death/dying issues, and actively participating in quality assessment performance improvement teams and activities are also expected. Finally, the social worker assists the family and patient in planning for funeral arrangements, financial, legal, and health care decision responsibilities. Other duties may be delegated by the Clinical Supervisor.
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Career Level
Mid Level