The Hospice Transitions Social Worker approaches the hospice discharge planning process with a patient-centered approach during a time when curative measures no longer add quality-of-life. The Hospice Transitions SW is responsible for evaluating and establishing a plan of care for Memorial Medical Center patients referred for hospice services. This includes detailed coordination between providers, agencies, colleagues, the patient, and the family. The Hospice Transitions SW 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. Embodies the Memorial Health System Performance Excellence Standards of Safety, Quality, Integrity and Stewardship that support our mission, vision and values.

Location: Springfield, IL

Please note this position is ONSITE 5 days per week Mon - Fri from 7:30am - 4pm and has no on call responsibility.

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 (for Advanced Care Management, required within six months of hire date).

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:
• 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.
• Current driver’s license and transportation.

Principal Duties & Responsibilities:
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.