As a member of the multidisciplinary team, the Palliative Care Social Worker (PCSW) assesses the psychosocial needs of the palliative care patient and provides clinical support to help meet patient/family social, emotional, and financial needs related to the impact of serious illness. Fosters trusting and supportive relationships with patients and their families, working alongside medical providers in a collaborative team by maintaining rapport and open lines of communications with patient to ensure their needs are met and continuity of care is maintained. Evaluates and assesses patient needs for discharge planning assistance, planning and coordination of patient programs, and acting as a liaison between the patient, hospital, physician and community in the post-acute care with appropriate linkage of community services/resources. Demonstrates behavior, autonomy and decision making consistent with the values and ethical guidelines of the hospital as well as the professional code of ethics. Embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values.

Shift: Mon - Fri 7:30am - 4pm

Minimum Qualifications:
Education:
• Master’s degree of Social Work from a School of Social Work accredited by the Council on Social Work Education
Licensure/Certification/Registry:
• Illinois Licensed Social Worker required. May be obtained within 6 months as a condition of employment.
• Licensed Clinical Social Worker preferred.
Experience:
• Experience working with adults across the life span presenting with chronic or serious illness
• Experience identifying and coordinating the needs of chronically ill patients and families as well as supporting the care team
• Understanding of psychosocial implications of illness, hospice and/or home care death and dying issues.
• Knowledge of local community resources.
• Knowledge and understanding of individual development and human behavior as it relates to the effects of illness and of the influence of culture on healthcare
Other Knowledge/Skills/Abilities:
• Demonstrated ability to communicate with physicians, nurses and members of the multidisciplinary care team to collaborate in developing patients’ plans of care.
• Flexible problem solver who is eager to tackle complex problems and tasks
• Excellent verbal and written communication skills; ability to solve problems creatively
• Ability to work across multiple sites of care and multiple members of a care team while managing competing commitments through clear communications
• Ability to work in a changing and ambiguous environment.
• Self-starter with initiative
• Experience identifying issues and developing and implementing solutions
• Must possess strong oral and written communication skills, planning skills, problem-solving skills, and personal diplomacy skills.
• Demonstrates personal traits of a high level of motivation, team orientation, professionalism and trustworthiness.
• Excellent PC skills, including the use of Microsoft Office products. Familiarity with EMR clinical products preferred.

Principle Duties & Responsibilities:
1. Care Delivery
a. Functions as a member of the interdisciplinary Palliative Care team across the health system to ensure high quality, patient-focused care.
b. Communicates effectively and compassionately with patient, family, and health care team members about serious illness.
c. Demonstrates respect for the patient’s views and wishes regarding healthcare treatment.
d. Incorporates ethical principles and professional standards in the care of patients and families experiencing life-limiting, progressive illnesses as well as identifying and advocating for the wishes and preferences of patients and families.
e. Conducts patient and family meetings with the members of the interdisciplinary team to discuss the goals of care, assist with decision making and advance care planning, determine care preferences, and develop patient-centered care plans
f. Work closely and collaboratively with the clinical care team across sites of care
g. Provides consultation to colleagues for complex patient care and family situations
h. Engages pastoral care, ethics, case management, social work, pharmacy, nutrition and other specialties as needed to address the complex needs of palliative care patients.

2. Psychosocial Assessment
a. Conducts patient assessments and develops the plan of care for delivery of serious illness care in collaboration with physician(s) and members of the multidisciplinary care team.
b. Utilizing specialized knowledge and experience, makes assessment of palliative care patients’ psychosocial needs, home situation, and economic constraints

3. Counseling
a. Provides crisis intervention and supportive counseling for palliative care patients and their families as needed
b. Assists the patient and family to cope with psychosocial symptoms
c. Provides short-term counseling to patients and families related to serious illness
d. Uses interpersonal skills to coach, inform, negotiate, and solve problems and conflicts as they arise.

4. Community Resources
a. Serve as liaison between patients/ families and community agencies
5. Embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values:
• SAFETY: Prevent Harm - I put safety first in everything I do. I take action to ensure the safety of others.
• COURTESY: Serve Others - I treat others with dignity and respect. I project a professional image and positive attitude.
• QUALITY: Improve Outcomes - I continually advance my knowledge, skills and performance. I work with others to achieve superior results.
• EFFICIENCY: Reduce Waste - I use time and resources wisely. I prevent defects and delays.

6. Care Transitions
a. Confers with the patient, family, and clinical team to obtain information to coordinate efficient and quality patient care across the continuum
b. Builds relationships with primary care providers, skilled nursing facilities, and the community to promote continuity of care
c. Assures that all necessary information has been transmitted to next provider of care.

7. Support
a. Serves as patient advocate, assisting with navigation of patient eligible resources and programs
b. Provides patients and families with support and information to overcome personal and environmental difficulties which pre-dispose toward illness or interfere with obtaining maximum benefits from medical care
c. Assist patients to effectively utilize available resources to meet their personal health needs and help them develop their own capabilities

8. Advance Care Planning
a. Maintains a working knowledge of relevant medical/legal issues that impact patient care, e.g., advance directives, power of attorney, and guardianships.

9. Documentation
a. Documents all interactions and care provided to patients and families through psychosocial assessments and re-assessments, crisis intervention, individual and/or family counseling, bereavement counseling, emotional support, and discharge planning.

10. Quality
a. 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.

11. Education and Training
a. Assists, as needed, in training, new colleague orientation, student education, community education, in-house activities, and general public relations activities.
b. Demonstrates knowledge of care for older adults through accurate assessments, treatment and effective implementation of interventions.
c. Participates in continuing education and in-service training to support professional growth and expertise.

12. Recognizes one’s own attitudes, feelings, values, and expectations about death and the individual, cultural, and spiritual diversity existing in these beliefs and customs.
a. Aware of and complies with department and hospital policy and procedures.

13. Adheres to the NASW Code of Ethics

14. Performs other related work as required or requested.

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.