This role is an essential component of providing comprehensive palliative care support to patients and families across the healthcare continuum. This role will serve patients and families within UnityPoint Health Des Moines Hospital, clinics and the community. This professional will participate in the development of an interdisciplinary plan of care in order to meet the needs of the palliative care patient and family. This person will serve to coordinate an integrated psychosocial support system for the palliative care patient and family to ensure successful transitions from various levels of care or at crucial points in the patient’s disease process.
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Care Coordination:
Maintains the standards of social work excellence in accordance with the scope and practice and standards of care set forth by the proper state chapter, NASW Standards for Social Work Practice in a Health Care Setting, and the Social Work Code of Ethics.
Performs comprehensive psychosocial and behavioral assessments, treatment plans and appropriate interventions and therapy for behavioral health illnesses and concerns in the palliative care setting.
Demonstrates ability to diagnosis behavioral health illnesses with use of DSM 5 and appropriate billing codes.
Conducts assessment, diagnosis and treatment of the social and emotional factors related to the patients/clients illness, need for care, response and adjustment to illness and care and completes appropriate patient-centered plan of care and interventions according to scope of practice.
Consistently utilizes a holistic approach considering physical, psych/social, spiritual, educational, safety and related criteria appropriate to the age of the patients served in assigned service area.
Works in collaboration with the palliative care providers and the other interdisciplinary team members to establish a plan of care for the patient that includes psychosocial symptom management
Identifies and refers patient/family/caregivers to appropriate individuals or agencies as necessary.
Maintains accurate and timely documentation of clinical records.
Departmental Support:
Participates in regular interdisciplinary team meetings.
Together with other interdisciplinary team members, organizes and conducts the patient and family meeting for the purpose of facilitating clear and ongoing communication regarding the patient’s plan of care.
Demonstrates a working knowledge of the various levels of care including acute care, skilled care, long-term care, and hospice.
Assists other team members in understanding significant social and emotional factors related to health problems and death/dying.
Assists other team members in understanding significant social and emotional factors related to health problems and death/dying.
Education: Master’s degree Required in social work, Marriage & Family Therapy or Mental Health Counseling or related field
Experience: One year clinical experience health care Required, preferably working with patients that are chronically ill.
License(s)/Certification(s): Licensed Independent Social Worker/Licensed Clinical Social Worker, or licensed at the highest level within their discipline, that the state allows. Valid driver’s license when driving any vehicle for work-related reasons.
Knowledge/Skills/Abilities: Ability to work as a collaborative team member. Excellent verbal and written communication skills.
Other: Use of usual and customary equipment used to perform essential functions of the position.
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