A member of the hospice care team and responsible for assessing, planning, implementing and evaluating patient and family needs with focus on psychosocial status, community resources and long term planning in accordance with physician orders. Assists and interacts with the multi-disciplinary hospice team members to optimize patient independence and safety.
1. Initiates, develops, implements and revises the patient’s plan of care.
2. Coordinates care with the multidisciplinary hospice team as well as patient’s primary physician, family members and
other community resources.
3. Provides an education plan for the patient / family / caregiver concerning knowledge deficits or needs regarding the
4. Assists patient / family / caregiver with acquiring in home help, access and knowledge about community resources,
supportive counseling as needed, assistance for long term planning and community education.
5. Maintains current knowledge of community resources to meet social, financial, medical and spiritual needs of patient /
6. Performs patient assessments which may include but are not limited to psychosocial assessment, functional
assessment, mental status assessment and lethality assessment.
7. Provides therapeutic interventions and or instruction in appropriate psychotherapy and life skills including but not
limited to assertiveness skills, coping skills, grieving process, problem solving, communication skills, stress management,
suicide precautions, behavioral modification techniques and impulse control techniques.
8. Demonstrates ability to adapt to patient / family / caregiver educational level and learning style and to deal effectively
with diverse cultures, lifestyles and patient / family / caregiver expectations.
9. Assessment, intervention, care-planning and evaluation include identification of support system and resources, barriers
to care/care progression, discharge coordination, referral and resources, psychosocial services.
10. Proactively manages care progression of patients to the appropriate level of care, recommends changes in plan as
needed to promote enhanced outcomes.
11. Performs other duties as assigned.
1. Proficiency in reading, writing, comprehending and speaking English as required for business necessity.
2. Accountability for HIPAA privacy and security standards within the department or assigned nursing unit.
3. Must possess basic skills to use Microsoft Office, specialized software and electronic office equipment.
4. Provide patient care, based on physical, psychosocial, educational, safety and related criteria, specific to the age of the
patient population served in the department or assigned nursing unit and specific to Medicare’s Conditions of
Participation, The Joint Commission standards of care and all national and state regulations.
5. Adheres to organizational patient safety standards relevant to the department or assigned nursing unit.
6. Accountable for daily assignment, demonstrates flexibility to accommodate new admissions and/or crisis situations.
7. Encourages the patient/caregivers toward independence in managing the disease process.
8. Completes all documentation in accordance with policy and procedure. Any and all paper documentation is submitted
in accordance with policy.
9. Communicates with and provides updates regularly to other team members, management, schedulers and physician as
needed. Obtains necessary physician orders as needed.
10. Checks email and voicemail a minimum of twice daily.
11. Begins discharge planning at first visit.
12. Responsible for continuous review of all aspects of every patient on his/her caseload including:
- Appropriate utilization of services
- Ensuring continued skilled need
- Reviewing documentation in the medical record
- Provides updates to the physician regarding the POC, including orders
- Provides updates to the insurance case manager, including obtaining insurance authorization when necessary
- Discharge planning
- Ensuring F2F requirement has been satisfied
- Other industry benchmarks.
13. Must utilize one or more Cerner and/or McKesson applications to deliver and track patient care.
14. Varied day-to-day activities which includes:
phone, email and written communication; visits to patients and their
family and meetings with a variety of healthcare professionals.
15. Works closely with nurse co-case managers to provide care and services for a group of hospice patients.
16. Provides expertise to the interdisciplinary team for psych-social assessments, interventions and knowledge of
17. Ability to utilize various teaching methods and to adapt these to patient/client and family’s educational level and
18. Must have age-appropriate developmental assessment skills.
19. Must have accountability for professional clinical practice, commitment to patient care, and commitment to uphold
the Patient Bill of Rights.
20. Must have maturity and interpersonal skills necessary to work successfully with an interdisciplinary team and deal
effectively with patients and families from a variety of backgrounds and with varied emotional and medical needs.
21. Time management skills to independently manage own caseload (i.e. to schedule visits, attend required meetings,
respond to urgent needs by prioritizing and triaging multiple concerns).
22. Demonstrates knowledge of regulations applicable to hospice including Medicare conditions of participation, JC
requirements, DOH requirements, and other industry benchmarks.
REQUIRED for the position:
- License, Certification, Education or Experience:
- Master’s Degree in Social Work (MSW)
- One of the following credentials is required:
oLicensed Independent Clinical Social Worker (LICSW)
oLicensed Advanced Social Worker (LASW)
oCredentialed as an Agency Affiliated Counselor (AAC)
oSocial Worker Associate License- (LSWAA) or (LSWAIC)
- If you were hired prior to January 2012, then you may also have one of the following:
oLicensed Mental Health Counselor (LMHC)
oLicensed Mental Health Counselor Associate (LMHCA)
DESIRED for the position:
- One-year social work experience in a related health care setting
- Current Healthcare Provider BLS certification by date of hire
- Previous hospice or home health care experience
This position is covered by a collective bargaining agreement between EvergreenHealth and the Service Employees International Union (SEIU) Healthcare 1199NW. Union Membership is optional.