Sign-On Bonus Up to $15,000!!

Join Memorial Health and make a real difference in the lives of patients and their families. As a Hospice Transitions Social Worker (LSW) with an MSW degree, you'll play a critical role in the hospice discharge planning process, with a patient-centered approach during a time when curative measures no longer add quality-of-life. 

What We Offer:

• Up to a $15,000 Sign-On Bonus to welcome you to our team!
• 40 Hours of Front-Loaded PTO
• Flexible time off and remote on-call options, with minimal need to return to the hospital.

Key Responsibilities:

• Evaluate and establish a plan of care for patients referred for hospice services
• Coordinate between providers, agencies, colleagues, the patient, and the family
• Assesses the needs of the patients and provides counseling to patients and their families while coordinating the transition to hospice and promoting continuity of care

Bring your LSW license and MSW degree to a dynamic team and help improve the patient and family hospice experience through compassionate, proactive care.

• Master’s degree of Social Work from a school of social work accredited by the Council on Social Work Education. 
• IL Licensed Social Worker required within 6mo of hire. 

1. Embodies the Memorial Health System Performance Excellence Standards of Safety, Quality, Integrity and Stewardship that support our mission, vision and values:

• SAFETY: Prevent Harm - I will put safety first in everything I do.  I will speak up, without fear, on matters of patient and colleague safety.  I will take action to create an environment of zero harm.

• QUALITY: Improve Outcomes -  I will continually advance my knowledge and skills.  I will seek out continuous improvement opportunities.  I will deliver evidence-based care that leads to excellence in outcomes.

• INTEGRITY: Show respect and Compassion  - I will respect others and show compassion.  I will behave honesty and ethically.  I will be accountable for my attitude, actions and health.

• STEWARDSHIP: Reduce Waste - I will use resources wisely and maintain financial stability.  I will work together to coordinate care and services across the health system.  I will promote healthier communities.

2. Upon referral, processes and develops the hospice discharge plan by reviewing the referral information, medical record, and advance directives. Collaborates with appropriate decision maker and appoints a health care surrogate when necessary.

3. Meets with patients, families, caregivers, physicians, and ancillary team members to discuss the hospice transition process. Provides an overview and education about hospice including comfort focused care, hospice philosophy, hospice services, possible hospice discharge options, and financial/insurance coverage.

4. Utilizing specialized knowledge and experience, makes assessment of patient’s psychosocial needs, home situation and economic constraints, utilizes resources as appropriate.

5. Assesses the relationship of the patient’s medical needs to the patient’s home situation, financial resources, and availability of community resources. Assists and supports patients and families in making arrangements for the post-acute care plan.

6. Formulates a discharge plan acceptable to the patient, family, and healthcare team. Facilitates adjustments to the plan of care when necessary to promote enhanced outcomes. Collaborates with all members of the healthcare team to develop, manage, and communicate patient needs and discharge plans.

7. Elicits choices for discharge disposition, hospice agencies, and skilled nursing facilities. Informs and educates about the discharge planning process including transportation options, DME delivery process, and services.

8. Sends SNF referrals when patients require placement and sends referrals to hospice agencies. Monitors referrals via naviHealth or regular phone contact with the hospice agency.

9. Facilitates/implements the care plan with proposed interventions in collaboration with the healthcare team. Collaborates with all members of the healthcare team to implement, manage, and communicate the transition of care arrangements.

10. Documents all interventions in the patient medical record both timely and accurately including all elements of the discharge plan. Performs transfer of accurate, pertinent, patient information between all appropriate entities of the post-acute care continuum.

11. Serves as an intermediary when providing community resources to patients, caregiver, and families. Discusses with patient, caregiver, and/or family maintaining clear communication regarding anticipate discharge date and potential care settings.

12. Maintains knowledge of Medicare, Medicaid, and other program benefits to assist patient with transition of care planning and choices.

13. Develops and maintains contact with key hospital, skilled nursing, assisted living, discharge planning services, case management, and clinical staff to provide ongoing updates in the discharge planning process. Confers with leader on any unusual situations and communicates plan and activities for patient discharge across the care continuum.

14. Communicates with the physician to verify that the patient is stable for discharge, inform the patient and family about the discharge plan, makes final arrangements, and arranges transportation.

15. Assists patients and families in making healthcare decisions based on personal goals-of-care. Assist patient and family with social concerns associated with the dying process by utilizing social services assessments, life review counseling, etc.

16. Maintains up-to-date, accurate, and appropriate documentation daily.

17. Ensures that patients’ end-of-life wishes are documented and known by assisting with advance directives, do not resuscitate orders, or POLST forms.

18. Adheres to department productivity standards.

19. Participates in the monitoring of quality and utilization metrics and participates in improvement efforts to refine the delivery of care to maximize clinical, quality, and fiscal outcomes.

20. Assists, as needed, in the staff training, new employee orientation, student education, community education, in-house activities, and general public relations activities.

21. Refers to ancillary teams when warranted.

22. Aware of and comply with department and hospital policy and procedures.

23. Adheres to the NASW Code of Ethics.

24. Participates in continuing education and in-service training to support professional growth and expertise.

25. Performs other related duties as assigned.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.