Medical Social Worker

Pathways Home Health, Hospice and Private Duty•Sunnyvale, CA

39d•$39 - $59

About The Position

For over 45 years Pathways has been a Bay Area pioneer, leader, and innovator in Hospice, Home Health and Palliative Care. We provide care at home or in settings such as assisted living, a nursing home, or the hospital. We have offices in Sunnyvale, South San Francisco, and Oakland. Patients and their families know us for our personalized, high-quality care, delivered with empathy, kindness, and respect. POSITION SUMMARY: Provide medical social services including psychosocial assessment, counseling, and community resource information and referrals as part of the interdisciplinary home health and hospice teams.

Requirements

MSW degree from an accredited graduate School of Social Work.
One year of professional social work experience preferred.
Experience and demonstrated competence and comfort working with families in crisis, the frail elderly, the disabled and/or the terminally ill.
Current CPR Certificate.
California driver’s license and automobile insurance

Responsibilities

Provides education and counseling to current and prospective hospice patients and their families regarding the Pathways Hospice philosophy, plan of care, and services.
Obtains informed consent from patients and families and assists in completing forms required for hospice admissions and discharges.
Conducts comprehensive psychosocial assessments including an evaluation of patient/family coping, social service needs, caregiving plans, and bereavement risk.
Based on this assessment, develops a comprehensive psychosocial plan of care, including individualized goals, interventions, and projected visit frequencies. Continually reviews and updates psychosocial plan of care. Integrates input from other disciplines to create a comprehensive interdisciplinary plan of care.
Provides counseling and education to help patients and families resolve issues associated with end-of-life such as anticipatory grief, caregiver stress, anxiety, memory loss and other patient mental status changes.
Identifies and enhances the strengths of the family system, including maintaining the dignity of the dying patient, assessing impact of patient/family’s unique cultural and spiritual beliefs on patient’s end-of-life needs and educating the interdisciplinary team on this impact as needed.
Provides guidance, education and referrals to help patients and families access appropriate social services including caregiving resources, advanced planning needs, mortuary arrangements, and/or financial resources.
Consistently communicates with family members of both home- and facility-based patients. Maintains timely communication with patient, family, and facility staff regarding all aspects of patient care.
Provides discharge planning for hospice patients when moving to a different care environment or when hospice is discontinued.
Knowledgeably discusses and initiates non-pharmacologic interventions as appropriate to promote comfort, improve quality of life, and manage emotional, spiritual, and physical distress.
Knowledgeably assesses and manages risk factors in the hospice setting, including behavioral health issues. Conducts screening and follow-up of patients at risk for anxiety, depression, and suicidality. Provides guidance and leadership to other members of the interdisciplinary team regarding mandatory reporting issues such as abuse and neglect.
Provides periodic weekend on-call social work services including triage and crisis intervention.
Consults, collaborates, and coordinates with the IDG and others involved in the patient’s care all patient and family services based on the patient’s and family’s preference.
Attends and actively participates in IDG meetings, presenting relevant psychosocial information concisely and professionally. Also attends and actively participates in educational in-service trainings and other agency meetings as requested by Social Services Program Director/Manager.
Collaborates with the Volunteer Resources department to train, supervise, and consult with patient care volunteers.
Collaborates with Bereavement Department to evaluate bereavement risk factors, develop individualized bereavement care plans, and provide individual and/or group bereavement counseling and education.
Participates in facility patient care conferences, in coordination with other IDG members, to discuss and clarify hospice care goals and roles of team members. Initiates care conferences as needed.
Demonstrates awareness of and adheres to the safety, infection control, and other policies of the facility.
Participates in quality improvement activities related to areas of practice as appropriate.
Demonstrates all skills of a hospice social worker, including those skills required by the agency through competency testing.
Submits weekly visit schedule of assigned patients as appropriate. Collaborates with Clinical Team Manager(s) to address scheduling needs.
Assesses, develops, organizes and delivers teaching materials for assigned home care patients as appropriate.
Helps clarify, counsel and explain the use of medical recommendations, services and options offered to Home Health patients to restore, improve and/or maintain their optimal social and health adjustment within the patient’s own capacity.
Assists patients, families and staff to understand, accept and manage the significant social, emotional, and financial factors related to a patient's health challenges.