Changing health care
to improve quality of
life for all.
Beth Israel Lahey Health’s roots in providing top-quality health care date back nearly a century. We're fully committed to ensuring our patients receive the care they deserve. As a leading healthcare provider throughout New England, we aim to change the current state of health care for the better and make lasting improvements that guarantee access to our services.
Hospice Medical Social Worker
Watertown, MassachusettsOrganization Facility: Beth Israel Lahey Health at Home Category: Social Services Job ID: JR22358 Date posted: 05/22/2023
When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.
Work Shift:Day (United States of America)The Hospice Medical Social Worker provides a wide range of services to terminally-ill patients and families while consistently exercising judgment and discretion to determine the patient and family’s unique spiritual/ cultural beliefs, strengths, coping skills, and pre-bereavement and anticipatory grief needs. Assessment is ongoing and the Plan of Care reflects the Medical Social Worker’s analysis of and conclusions regarding unique bio-psychosocial needs of the patient/ family.
Direct Patient Care
- Coordinates social work services for hospice patients and their families
- Manages IDT patient plan of care for Hospice social work interventions
- Provides person and family centered, comprehensive psychosocial assessment
- Provides psychosocial interventions with the highest integrity related to cultural appropriateness and developmental stage along the continuum of illness including:
- supportive counseling
- anticipatory guidance
- facilitation of family meetings
- linkage to community resources
- non-pharmacological pain and symptom management
- Reinforces patient and family personhood and coping as they negotiate the complexities of serious illness
- Assesses risk and intervenes clinically to identify potential for complicated grief and explores anticipatory bereavement related to possible death and multiple aspects of loss and adaptation along the continuum of illness.
- Provides clinical guidance and consultation to interdisciplinary teams
- Provides safe and comprehensive care coordination and discharge planning as indicated. Assesses team coping with challenging clinical cases. Provides guidance and debriefing as necessary.
- Makes scheduled and unscheduled visits as a member of the Hospice Interdisciplinary Team to provide psychosocial assessment of patient/family functioning. Schedules and prioritizes visits based on the acuity level of the patient/family. Makes informational visits as requested by manager to prospective patients/families.
- Provides written psychosocial assessment of patient and family and communicates the following in a timely manner: psychosocial strengths and weaknesses, including coping skills, grief reactions, support systems, high risk factors for complicated bereavement and the need for community resources.
- Provides individual and/or family counseling and reassesses psychosocial factors during every visit to assure optimal outcomes. Initiates and /or participates in patient care conferences or family meetings as needed or requested and completes appropriate documentation in the electronic record.
- Upon assessing patient/family needs, the Hospice Social Worker makes all appropriate referrals to other community agencies in a timely manner; these include, but are not limited to accessing and applications for financial resources, nursing home placements, or transfer to the hospice house.
- As a Mandated Reporter, demonstrates knowledge of family violence, child/elder/disabled neglect and abuse so as to identify those at risk and refer them to appropriate agencies under the guidance of the Manager/Director. Demonstrates knowledge of crisis intervention theory.
- Facilitates or co–facilitates monthly support groups for IDT, and assists with the provision of a Bereavement Group support, as needed.
- Participates in weekly IDT meetings to provide ongoing updates, planning and revision of the POC as appropriate to patient/family changing needs and documented in biweekly updates. Participates in orientation, education, in-service training and QAPI [Quality Assurance Performance Improvement] program of Hospice.
- Provides consultation to other health professional personnel regarding psychosocial issues and provides in-service education as requested.
- Clinical visit notes support the need for hospice medical social services in light of the patient’s overall medical condition and experiences; the complexity of the services performed and the plan for the next visit based on the rationale of prior results.
- Initial assessment must be completed within 5 days of admission
- Completes documentation in accordance with agency timeliness policies.
- IDT notes completed timely including risk, and follow up plan