Job Summary

The Per Diem Social Worker (PDSW) is a member of the interdisciplinary team responsible for the care and co-case management of patient/families admitted to Hospice of Santa Cruz County's adult and pediatric services. The PDSW in collaboration with pt/family, physician and interdisciplinary team, develops, supports and coordinates an individualized Plan of Care (POC) that reflects pt/family goals related to safe and comfortable adult/pediatric life-limiting Illnesses, enhancing quality of life for adult/child and family and promoting self-determined life closure and effective bereavement. The PDSW demonstrates sensitivity, compassion, and cultural awareness for the range of issues involved with serving patients and families facing a terminal illness, death, and bereavement. The PDSW might provide cross-coverage for other agency social work functions/roles as determined by operational needs. Occasional weekend and holiday availability required.

Essential Responsibilities

Patient and Family Care/Case Management

• Recognizes the patient and family as a "unit of care"
• Develops/supports an individualized documented plan of care reflecting patient/family goals and provides social work services as outlined in the plan of care
• Identifies and monitors potential psychosocial hot spots.
• Leads/co-leads goals of care/advance care planning conversations that are culturally appropriate and patient/family-centered
• Provides co-case management support for issues related to care giving, advance directives, funeral planning, community resources and insurance benefit oversight
• Provides co-case management support for issues related to grief and loss, family dynamics and psychosocial history
• Collaborates with IDT regarding changes in patient status and POC
• Interfaces effectively with staff in hospitals, facilities, and other referral partners.
• Exercises good clinical judgment in the performance of all duties
• Understands and properly utilizes changing network of community resources
• Respects patient/guardian right to self-determination and acts as an advocate within the context of the vision, mission, values and ethical standards of HSCC.
• Assists Admission department with resourcing, assessment, information and registration process as requested
• Ensures documentation is accurate, organized, legible, and a complete reflection of services provided as well as an interdisciplinary approach to care. Utilizes only approved abbreviations to ensure clarity of documentation
• Demonstrates the ability to articulate the parameters of hospice care and services
• Demonstrates the ability to work with patients/families under stress and in crisis
• Demonstrates understanding of Hospice Medicare/Medi-Cal Benefit and third-party payors
• Demonstrates professional demeanor, tact, and respect in dealing with all patients, families, staff and volunteers
• Responds with flexibility to the changing needs within the assigned caseload and within the social work department as a whole
• Performs other related job duties as assigned by Supervisor

Compliance

• Ensures all HIPAA Privacy and Security Regulations, Medicare Conditions of Participation, State and Federal Laws and all other regulatory/compliance requirements are understood and followed
• Submits verification of MSW degree from accredited school, passes OIG/GSA and background checks
• Submits acknowledgement of auto insurance annually; keeps drivers license current and maintains a good driving record
• Ensures TB checks are completed in a timely manner; at least annually

Productivity

• Manages a caseload or provides visit support as required by performance standards
• Provides visit frequencies that are within established agency standards
• Follows all requirements for obtaining approval for overtime
• Completes Psychosocial Assessment in a timely manner as required by performance standards
• Provides concise and timely reports to appropriate team members as required by standards
• Documents in a timely manner, all activities and services provided using electronic medical records systems
• Submits completed time logs within the required time frames

IDT Participation

• Functions as a member of the IDT maintaining open & organized communication with hospice staff, volunteers, and the supervisor.
• Functions as a social worker for adult and pediatric patients and their families in the coordination/provision of care.
• Participates in IDT meetings in a manner that promotes problem solving, care planning and learning.

Quality Improvement

• Meets all standards and requirements as indicated by licensing and accrediting agencies
• Participates in continuing education opportunities both within and outside the agency
• Participates in activities that affirm, enhance and develop the highest quality standards for HSCC
• Participates in Quality Assessment & Improvement activities as requested

Special Projects

• Participates in special projects as requested.

Requirements

Education

• Master of Social Work degree required from a school of social work accredited by the Council on Social Work Education.

Experience

• Minimum of 1 year of Social Work experience in a healthcare or mental health setting required
• Prefer previous experience in hospice or other end-of-life care and services
• Prefer previous experience working with the pediatric population
• Solid experience and/or aptitude with computer systems and electronic medical record systems and charting

Skills Desired

• Strong verbal and written communication skills
• Skilled in tact and diplomacy
• Capable of bringing appropriate level of sensitivity and compassion to patients/families facing terminal illness, death and bereavement
• Skilled in leading goals of care/advance care planning conversations with sensitivity and cultural awareness
• Understands how to hold and apply appropriate boundaries for care
• Knowledge of community social work services, resources and operational standards
• Understanding of all applicable laws and regulations related to social work licensing
• Understands and utilizes solid ethics in decision making and activities
• Bilingual in English/Spanish highly desirable

Certifications, Licenses, Registrations

• LCSW or related license desirable but not required

Physical Demands

• Ability to travel to patient locations; includes ability to drive, negotiate stairs and walkways including uneven surfaces at private homes or facilities.
• Sufficient dexterity to utilize electronic record keeping systems, computers/keyboards and/or laptops and other related equipment
• Vision ability to read manual and electronic documentation, charts, office related equipment, instructions
• Hearing ability within normal range to elicit and detect pertinent information while communicating with patients and health team
• Speech to verbally communicate to assess and impart information concerning patient status; to complete patient/family teaching and to interact with health care team

Work Environment

• Performs services in private homes and care facilities and will experience a variety of settings and situations.
• Office work is performed in typical office setting.