Provides services to patients and their families to address needs incidental to hospitalization. Offers counseling, support, and assistance with transition planning, and provides direction for routine non-medical problems affecting patients and their families. Assists with patient planning and post-discharge coordination with outside agencies, nursing staff, and relatives. The role collaborates on discharge plans for patients needing post-hospice or post-inpatient care; helps patients, families, and caregivers determine an appropriate level of hospice care; and refers patients to outpatient resources as appropriate. It initiates and reassesses plans of care and patient teaching based on patients’ physical and emotional needs. Plans of care are based on patient assessments, including psychosocial factors that may impede care, relevant human-development theories, the impact of terminal illness, mental status, and family dynamics. Other job-related duties may be assigned.
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Job Type
Full-time