Evaluates initial and on-going emotional, social, financial, and spiritual status of patients/families assigned to caseload.
Makes the initial contact with patient/family within 3 days of admit.
Conducts initial assessment of patient/family’s psychosocial status. Completes “Psychosocial Comprehensive Assessment” form within 5 days.
Develops and documents individualized, realistic and goal-oriented plan of care for each patient/family.
Initiates bereavement discussion with patient/family. Develops initial bereavement plan of care.
Participates in the ongoing development, implementation & updating of integrated plan of care. Ensures that the POC for each assigned patient is updated at least every 2 weeks.
Provides ongoing assessment of patient/family status as reflected in documentation.
Develops professionally appropriate relationships with patient/family.
Determines & documents the family members who are most involved with the patient and how the family dynamics work.
Ensures that a decision-maker for the patient and family is determined and documented.
Determines what high-risk indicators are present in patient/family (mental health, suicide, drug/alcohol abuse, previous losses, child/adult abuse, violence, etc.), and whether these issues are new or long standing. Documents appropriate communication with facility staff regarding these issues.
Initiates discussion with IDT/facility staff members regarding patient/family dynamics and issues as appropriate.
Advocates on behalf of patient/family as needed.
Assesses patient/family need for individual counseling, support groups and spiritual support. Connects patient/family to appropriate resources.
FACILITY STAFF RELATIONSHIPS
Develops professionally appropriate relationships with facility staff members
Recognizes & honors the diverse cultures of the facilities & professionally works within their system.
Supports appropriate collaboration between facility & hospice staff.
Establishes professional relationships with key facility staff members.
Attends facility care conferences as scheduled.
Offers & provides support to facility staff members related to issues of death & dying.
Participates in educational in-services for facilities related to issues of death & dying.
Assures patients receive the best possible care by working collaboratively with the facility staff.
Assists patient/family in utilizing appropriate community resources
Assesses current resources of patient/family and payment source.
Determines what resources the patient/family qualifies for and assists in obtaining those needed.
Has a good knowledge base of community resources including but not limited to: burial/cremation/funeral services, cost, and coverage, County and State programs/services, transportation, housekeeping/personal care, spiritual/religious resources, respite, wills and legal issues.
Ensures adequate planning for patients being discharged due to ineligibility (PASAAR, communication with facilities, DME, etc.).
Responsible for assisting patients who wish to travel outside service area with making appropriate traveling arrangements (assessing whether they meet our traveling pt. criteria to stay enrolled, arrange coverage with another hospice, arrange for DME, supplies and medications, etc.).
Ensures adequate planning for patients who chose to revoke (PASAAR, communication with facilities, DME, etc.).
LONG TERM CARE
Assists patient/family in exploring long-term care planning issues
Explores patient/family goals regarding where patient dies, goals for the remainder of his/her life, and determines feasibility of goals.
Determines current resources available and additional possible resources to help the patient/family attain goals.
Effectively facilitates a change in location of patients involving home, assisted living residence, hospital, or long term care facility.
Completes appropriate paperwork (ie:PASARR) when patient moves from one location to another.
ADVANCE PLANNING CARE
Responsible for facilitating team’s participation in Advance Care Planning Process with patients and families
Keeps the team focused on the process of Advance Care Planning rather than on obtaining a document.
Determines what Advance Directive documents the patient has completed and obtains a copy of those documents for the chart. Discusses content of documents with patient/family to clarify details and update information.
Assists patient/family in recognition and understanding of significant social, emotional, and cultural factors related to end of life and communicates to IDT members.
Assists with pre-admission visits and assessments as assigned
Makes presentations to patient/family, explaining hospice benefits and services provided.
Assists Palliative Care Liaisons / admitting nurse with pre-admission visits and assessments.
Participates in the bereavement process.
Obtains Family/Friends form from patient/family during first visit and assists in completion if necessary; gives completed form to appropriate Team Assistant, who enters into Suncoast and gives copy to assigned social worker.
Does bereavement risk level assessment for each family/friend listed on Family/Friend form. Also determine if other individuals need to be added to list. Ensures that the bereavement risk level is entered into Suncoast.
Reviews file for each family member and friend in Suncoast to determine if information is correct. Reviews each file to determine if they have utilized any other HPCWC services in the past.
At IDT, facilitates team in evaluating Suncoast information for accuracy, adds any missing information; adds note to comment box with date information requested, lists information needed and who is responsible for obtaining information. The team is responsible for insuring all family members and friends needing bereavement are on the list; team will continue to evaluate whether individuals on the list are appropriate for bereavement follow-up. Appropriate information will be added in comment section (mental health issues, alcohol/drug use, previous losses, family dynamics, etc.).
At time of patient’s death: Reviews individuals listed in Suncoast as family and friends for appropriateness of being admitted to bereavement program; determines final risk level for each and reviews for missing information and locates needed information.
Notes in comment section the reason any individual is not admitted into bereavement so other staff knows the status.
Takes appropriate steps to add family/friends needing bereavement services as determined by social worker/team.
Facilitates closure visits and funeral/memorial services attendance for team.
Facilitates groups and participates in camps as assigned and agreed upon.
Prepares appropriately for assignment.
Fulfills agreed upon duties and assignments.
Completes necessary paperwork in a timely manner.
Completes documentation of visits/phone calls & submits per agency standard.
Plan of care is initiated at admission and then updated per organization policy.
Documentation of visits and phone calls turned in per agency standard at least 95% of the time.
Reviews and updates bereavement information in data base within two weeks of patient’s admission to Hospice.
Completes bereavement responsibilities within one week of patient’s death.
Participates in Psychosocial on-call rotation as scheduled
Remains available by hospice cell phone/within pager range.
Responds by telephone to all calls and/or pages within 15 minutes.
Makes visits within 30 minutes of call unless there are extenuating patient related circumstances (at another visit, pt. /family ask for visit at different time, etc.).
Conducts visits and/or phone calls during on-call hours as needed.
Communicates appropriately any schedule changes and/or inability to provide on-call coverage as assigned.
Master’s Degree in Social Work from an accredited social work program AND personal or professional experience in the provision of spiritual care support to individuals and/or groups.
Must have completed a minimum of two (2) units, or be in progress of completing, Clinical Pastoral Education training or equivalent training.
Must apply to become a Registered Psychotherapist, Licensed Social Worker (LSW), or Clinical Social Worker (CSW) with the State of Colorado Department of Regulatory Agencies (DORA) within first month of employment. Must keep manager and HR updated on status of obtaining registration or license. New hires are required to be registered or licensed within 90 days of employment. Employees must maintain registration or license throughout employment with HopeWest.
Have a least two years social work experience with a focus on both resource finding and supportive counseling.
Maintains a program of reading, formal education, experiences, spiritual development, clinical supervision and peer review.
Participates in monthly peer review with chaplains of HOPEWEST
Minimum of one (1) year supervised experienced in the health care field or during a supervised internship.
Ability to cope with patient/family emotional stress within the framework of the Hospice philosophy.
Reads, writes and speaks English in a manner that can be understood by others.
Ability & willingness to gain a thorough understanding of community resources.
Effective communication, problem-solving customer relation skills to build rapport with facility staff members to enhance quality care to patients.
Ability to interact appropriately with geriatric populations and clients with cognitive behavior impairment and other various barriers to communication.
Have the ability to work as part of an interdisciplinary team.
Have organization skills relevant to linking hospice to community.
Have excellent verbal and written communication skills.
Have a valid Colorado driver’s licenses with unlimited access to reliable transportation.
We are one team - from patient care to administration - working together to improve the quality of life for those facing serious illness and grief in Western Colorado. The patients and families we serve teach us new lessons about living. We love our work. Everyday we see miracles of human caring, compassion, strength and courage.HopeWest has been recognized for three consecutive years as a Best Co...mpany to Work for in Colorado! We have many special things that make us a great company to work for including tuition reimbursement programs, paid educational and conference opportunities, discounts on memberships and services throughout the Grand Valley and movie and concert tickets. Employees have a very positive attitude and make our organization a friendly and fun place to work.