The Medical Social Worker is responsible for the implementation of standards of care for medical social work services within Palliative Care Services.  This may include provision of care for both inpatient and outpatient services.

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• Performs patient care functions as required.
• Assumes responsibility for the psychosocial plan of care through the episode of care for a patient or group of patients, per department standards for the specified patient population.
• May assume responsibility or assist with case management for palliative care patients and families working closely with the nurse practitioner or registered nurse.
• Performs psychosocial assessments and plans interventions based on assessment findings. This includes the psychosocial status of patients/families/caregivers related to the patient’s serious illness an environment.  Provides a comprehensive assessment in the patient’s identified residence and assists when this is not safe and another plan is required.
• Functions as a mandatory reporter and reports any suspected abuse and /or neglect.
• Assumes responsibility for developing a plan of care that is mutually established with the patient and family. Each patient is treated as an individual, with their identified goals and expectations reviewed each visit to verify priorities.
• Implements the plan of care according to current standards of social work practice, evidence-based practice, hospital protocol and procedures and selected competencies approved for the care of the designated patient population.
• Continually evaluates psychosocial outcomes by assessing and re-assessing patient and family responses. Updates the plan and goals of care to reflect changes in needs.
• Integrates interdisciplinary approach to maintain comfort, support human functions and responses, and maintain an environment conducive to safety and well-being. Implements measures to promote a safe environment.
• Assesses need for patient and family education. Provides health literacy teaching and counseling, as appropriate.  Facilitates referrals to appropriate resources.
• Interdisciplinary patient charting is done concurrently as care is provided to assure that goals of care and patient outcomes are being achieved.
• Partners with the healthcare team to achieve the patient care outcomes and goals of care. In addition, collaborates with care coordinators when patient is readmitted to the hospital.
• Counsels patient/family/caregivers as needed in relationship to stress and other identified coping difficulties.
• Provides information and referral services for organizations, patients/families/caregivers regarding practical and environmental needs.
• Provides information to patients/families/caregivers about community agencies and acts as a liaison in this referral process.
• Serves as liaison between patients/families/caregivers and community agencies.
• Maintains collaborative relationships with Palliative Care team members in support of patient care.
• Participates in the development of the Palliative Care interdisciplinary plan of care and attends interdisciplinary team meetings weekly.
• Assists physician and other team members in understanding significant social and emotional factors related to serious and/or terminal illness and death/dying issues.
• Identifies bereavement risks and refers appropriately.
• Assists patient/family/caregiver with securing advance directives including durable power of attorney for healthcare and living will, as needed.
• Actively participates in department performance improvement and strategic planning.
• Arrives on time for assignments. Seeks and obtains sufficient information necessary to function effectively in the Palliative Care setting where patient/family/caregiver is requiring care.
• Assesses the environmental safety for a patient.
• Identifies and addresses cultural concerns and preferences.
• Assists families with changing expectations and roles as the illness progresses.

Communication and Handoffs

• Demonstrates good verbal and written communication skills with patients, families, healthcare team members and other customers. Verbal communication is clear and precise.  Written communication is legible, if handwritten, and done in a timely manner using approved abbreviations.
• Computer documentation is done in accordance with hospital and unit policies.
• A critical component of our C.A.R.E. Model is the relationship between the patient and the caregiver. That relationship is built by time, communication and demonstrating compassion.
  • “Take 5” (taking 5 minutes) is used to make a personal connection with the patient/family to give the healthcare you would want your loved ones to receive. The connection adheres to all Standards of Excellence.  In departments with brief outpatient encounters, communication is based on AIDET (Acknowledge the patient, Introduce oneself, inform the patient of the Duration of the procedure, Explain what to expect and Thank the person for coming).
• Handoffs are done with attention to detail and with safety as a high priority. Tools such as SBAR (Subjective, Background, Assessment, Recommendations) are consistently utilized to assure that critical information is clearly communicated, shared and updated with each handoff.  SBAR handoffs are utilized to communicate patient treatment and assessment information, patient education needs, goals of care and other quality care measures.
• Supports evidence-based clinical practice and questions the rationale and scientific basis for clinical practice and/or changes in practice.
• Complies with changes in clinical practice and standards.
• Participates in data collection when the opportunity is presented.
• Supports/participates in interpretation of clinical literature and uses to validate and/or change clinical practice.
• Demonstrates flexibility and self-direction in meeting patient and unit needs by responding as a team player.
• Assesses and provides for educational opportunities for patients, families and other healthcare team members based on adult teaching-learning concepts and health literacy principles.
• Assists in the orientation of new associates by acting as a resource and mentor to associates. Collaborates with unit leadership, as appropriate.  Serves in preceptor role, as appropriate.
• Participates in the education experiences of students.
• Provides professional leadership through compliance with established unit routines, policies and procedures.
• Assists in creating a positive work environment that contributes to safety and positive clinical outcomes. Supports recruitment and retention of staff to assure an adequate workforce for clinical care.
• Assumes accountability for own competence, clinical performance and professional growth.
• Continually maintains and strives to enhance personal, technical and clinical competence in all job related duties.
• Specialty certifications encouraged.
• Participates in appropriate professional organizations.
• Participates in mandatory education and unit staff meetings per established guidelines.
• Encouraged to make and support improvement in unit and hospital practices through participation in shared governance and performance improvement activities at the unit and hospital-wide level.
• Complies with established safety goals, infection prevention and risk management policies and procedures.
• Performs other duties as deemed necessary to meet the hospital’s mission, to give the healthcare we’d like our loved ones to receive.

• Graduate of a Masters’ program in Social Work accredited by the Council on Social Work Education.
• Has obtained Licensed Masters Social Work certification (LMSW)
• Licensed in the State of Iowa.
• Writes, reads, comprehends and speaks fluent English.
• Understands Palliative Care philosophy and issues of disease progression and death/dying.
• Understanding of end-of-life care, grief and loss, and alleviation of suffering.
• Effective verbal and written communication skills. Ability to provide complete written documentation in a timely manner.
• Is self-directed with the ability to work with little supervision; has good organizational skills.
• Is flexible and cooperative in fulfilling role obligation and has ability to work with an interdisciplinary team.
• Assumes responsibility for maintaining clinical expertise in Palliative Care, end-of-life care and grief/loss.
• Must be familiar with ethical principles and comfortable in applying them to clinical situations.
• Use of usual and customary equipment used to perform essential functions of the position.
• Collaboratively interacts with St. Luke’s Hospital associates, physicians, patients, families and community in a professional manner.
• Participates in interdisciplinary improvement initiatives. Develops and nurtures collaborative interdisciplinary relationships.
• Maintains flexibility with scheduling of hours and travel as needed.
• Must demonstrate a cooperative, courteous and dependable working performance.Adapts positively and constructively to a constantly changing healthcare environment.
• Must possess high integrity and maintain confidentiality at all times.