Provides in-home services to our patients.

• Evaluates and develops a plan of care personalized to fit the patient’s psychosocial needs.
• Assesses the psychosocial status of patients and families/caregivers related to the patient’s terminal illness and environment and communicates findings to the interdisciplinary care team.
• Counsels patient and family/caregivers as needed in relationship to stress and other identified coping difficulties.
• Provides crisis intervention when necessary.
• Educates family/caregivers on, and assists in, preparation of advanced directives.
• Assists family and patient in planning for funeral arrangements, financial, legal and health care decision responsibilities.
• Assesses any relationships of the patient’s medical and nursing/therapy needs in the home setting, financial resources and available community resources.
• Observes, documents and reports changes in the patient’s condition to the interdisciplinary care team and Clinical Manager.
• Actively participates in quality assessment performance improvement (QAPI) teams and activities.
• Able to supervise/instruct the performance of the Social Work Assistant (BSW/LSW) to assure that all medical social services are provided to patients in compliance with company, government and professional standards as applicable.
• Maintains and submits documentation timely per company policy including any case conferences, patient/physician community contacts, visit reports progress notes.