PALLIATIVE CARE SOCIAL WORKER, Heart

PALLIATIVE CARE SOCIAL WORKER, Heart-(3276887)

Description

HEART PALLIATIVE SOCIAL WORKER / FULL TIME/ 40 HOURS/ BWH CARE CONTINUUM/ BOSTON MA

• SIGN ON BONUS AVAILABLE!
• LICSW or LCSW
• Brigham and Women’s Hospital, a nationally ranked academic medical center
• Grow and learn through regular internal continuing education programming, financial support for continuing education courses and conferences, and mentorship.
• Ask about our SIGN ON BONUS for eligible candidates! (Non-MGB employees)
• Excellent benefits: generous Paid Time Off; 403B match; cash balance pension; tuition reimbursement of $5,250/year, including continuing education; medical and dental; short-term disability; MBTA pass subsidy; and much more.
• Convenient public transit/ T-accessible Longwood Medical area location at the Main Campus at 75 Francis Street, Boston.

ABOUT THIS PALLIATIVE SOCIAL WORKER JOB:

The Palliative Care Social Worker (LCSW or LICSW) with experience working in a large, fast-paced academic medical center with inter-professional team focusing on patients with Advanced Heart Disease and their families. Social Worker will utilize their palliative care clinical skillset, effective communication, familiarity working with patients with serious illnesses, and competence working with interprofessional colleagues, as well as others in the Cardiology specialties (e.g., transplant).

The "HeartPal" team works very closely with one another, along with the primary medical teams, integrating knowledge and skillsets and dedicating time to provide comprehensive assessments, treatment plans and next-step recommendations, as well as assisting in developing disposition plans in collaboration with the primary and specialty teams. The HeartPal social worker must have familiarity with conducting and/or participating in family meetings, serious illness communication, as well as comfort providing “anticipatory guidance” to patients and their loved ones.

The HeartPal social worker will dedicate time in the out-patient setting working with patients referred to the HeartPal program by cardiology providers. The HeartPal social worker will have dedicated time to work on relevant mezzo and macro projects will be a part of the BWH Palliative Care, HeartPal Program, which provides palliative care to patients with heart disease across the care continuum, including in-patient, out-patient and dialysis settings. The BWH HeartPal team is inter-professional and includes an experienced palliative care social worker, palliative care nurse practitioner and palliative care physician. The HeartPal Program is a collaboration between the Departments of Psychosocial Oncology and Palliative Care, and Care Continuum Management at Brigham and Women’s Hospital.

The Palliative Care Social Worker is a key member of the inter-professional team, providing and overseeing the provision of palliative care, and, in particular, psychosocial interventions for selected patients and families. Some of the core tasks include: identifying psychosocial and emotional factors that impact the health status of patients/families; formal and informal teaching and modeling the role of palliative care in the course of serious illness; and practicing effective communication strategies to elicit and document patients’ values and goals to inform health-related decisions. The Palliative Care Social Worker provides clinical services to patients/families that address environmental, age-specific and cultural issues to maximize emotional, social and physical well-being and effective use of health care and community resources. The Palliative Care Social Worker collaborates with the medical team and provides social work consultation within the hospital and community during care transitions to increase continuity when patients are most vulnerable.

The Palliative Care Social Worker is an effective inter-professional team member and is attuned to team dynamics. Core tasks to promote teamwork include: participation in, contribution to, and implementation of processes to support team cohesion and sustainability. The BWH HeartPal Social Worker will participate regularly in team meetings and contribute to program planning, implementation, and evaluation, as well as presentations in both clinical and other, broader settings. The Palliative Care Social Worker will ensure documentation of patients’ values and goals and will facilitate referrals to appropriate clinical care teams within the hospital during admissions, as well as across care transitions.

Twenty percent (20%) of this full-time position will be dedicated to program development, measurement and education. Working closely with the HeartPal team, the Palliative Care Social Worker will represent, advocate, and teach other clinicians the psychosocial, emotional and spiritual needs of this patient population.

The Clinical Social Worker reports directly to the Manager, Palliative CareSocial Work, Dept. of Care Continuum Management. The Clinical Social Worker will be provided mentoring by the Heart Pal inter-professional team and will have opportunities to collaborate with other palliative care social workers.

Job Responsibilities:

• In collaboration with the patient, complete accurate and thorough advance care planning documentation.
• Ability to clinically assess the variety of factors that may impact goal-concordant care planning and contribute concerns and conclusions that can help guide both the patient and team in this planning process.
• Working with primary and HeartPal teams to triage patients who can benefit from specialty HeartPal Social Work support/follow up or referral to other services.
• Working collaboratively with the patient and family to identify community resources upon discharge, when applicable.
• Assessing psychosocial functioning and barriers to patient/family centered care and provide interventions to support goal concordant care.
• Promoting cultural humility
• Supporting diversity, equity, and inclusion with patients, families and colleagues.
• Developing clinical formulations and recommendations from a psychosocial professional lens and sharing these observations and recommendations with the interdisciplinary team with the goal of treating the ‘whole patient'.
  

PRINCIPAL DUTIES AND RESPONSIBILITIES

Clinical Practice:

• Provides assessment of patients to evaluate mental health/psychiatric history/emotional issues/coping style, understanding of illness/adjustment/compliance, barriers to care, cultural issues, abuse/neglect and domestic violence.
• Provides psychosocial assessment of families to determine family relationships/systems as they relate to care of the patient. Identifies family decision makers and caregivers; family understanding of illness and trajectory of care. Identifies family coping style, family resources and cultural issues.
• Employs a range of clinical interventions such as individual, group or family counseling. Provides caregiver/family counseling/support to promote family cohesiveness to provide care to patient and prepare families for end of life. Advocates on behalf of patients and families to gain access to services and resources. Refers patients to other providers, as necessary.
• Develops comprehensive bio-psychosocial assessments responsive to age appropriate and cultural needs and concerns. Employs a range of clinical interventions such as psychotherapy (individual, couples, families, and group), psychosocial counseling, crisis intervention, care coordination, complementary therapies, information and referral and safety planning. Advocates on behalf of patients and families to gain access to services and resources.
• Provides mandated assessments when abuse is suspected (child, disabled adult, elder) and safety assessment when domestic violence is reported. Files reports as indicated.
• Identifies patients’psychosocial, financial, legal, psychiatric or substance use that effect patient care management and collaborates with the team to facilitate patient care process.
• Works effectively as part of the interdisciplinary health care team, communicating regularly with the team and other members on cases and as issues arise. Documents timely and relevant information.
• Coordinates family/team meetings, as needed and when appropriate. Provides psychosocial consultation on patient care planning and patient/family management and community resources. Implements psychosocial programs based on patient/family identified needs.
• Facilitates the appropriate and efficient use of hospital and community resources.
• Participates in formal and informal clinical case reviews, clinical supervision, educational seminars and research projects.

Quality, Utilization Management: High Risk Psychosocial:

• Intervenes with appropriate individuals/departments/agencies regarding delays in service that may have an impact on quality of patient care, length of stay or inappropriate patient admissions.
• Reviews patient information for assigned caseload, determines anticipated length of stay and psychosocial barriers to plan of care transitions discharge plan in collaboration with the Nurse Care Coordinator
• Interacts with home care, community agencies and facilities to ensure safe and timely patient care transitions
• Negotiates with care coordination team follow up contact with patient/family, community agency or facility to evaluate the effectiveness of the patient care transitions and identifies problems in service delivery
• Ensures coordination of the communication process with patient/family concerning the plan of care, including coordination of family meetings and warm handoffs.
• Ensures that patient/family is involved in all phases of the care process to the greatest extent possible.
• Maintains current knowledge of and identifies needs in service delivery within social, governmental, protective services and legal agencies.
• Participates in data collection for departmental quality assessment activities in collaboration with the care coordination department.
• Participates in quality assessment/improvement activities designed to evaluate the appropriateness and effectiveness of the service delivery system in which care coordination operates.
• Ensures that the patient and family receive consistent information regarding all aspects of care.
• Communicates and collaborates with the Social Work Manager/Team to ensure efficient and quality patient care and equitable caseloads.

Leadership, Teaching and Education:

• Assesses patient/family learning needs, styles and readiness. Educates patients/families based on treatment plan, identifies barriers to care, diversity issues and learning styles.
• Mentors and may supervise students and staff. May teach in Departmental and Hospital seminars, workshops and rounds.
• Demonstrates expert social work clinical practice within the department and with interdisciplinary staff. Provides education and consultation to interdisciplinary health care providers, social work staff and community on psychosocial issues for patients.
• Demonstrates active, ongoing commitment to professional growth and development of self and creates an environment conducive to the professional growth of others.
• Participates in Departmental and Hospital committees. May participate in social work research.

Organizational/Administrative Skills:

• Takes responsibility for own administrative duties, including timely and appropriate documentation in patient medical records, timely and accurate daily reporting of activities and Hospital’s scheduling systems, and accurate reporting of time worked.
• Provides clinical documentation including psychosocial assessment, progress notes, and billing compliance (if appropriate).
• Attends and participates in Staff Meetings and interdisciplinary meetings/rounds.

Professional Conduct:

Adheres to and fosters compliance with NASW Code of Ethics, and Department and Hospital clinical, quality, compliance and safety standards, policies and procedures.

Supervisory:

Expected to mentor, precept, teach social workers and social work residents

Fiscal:

Meets Department productivity and standards. Ambulatory staff, ED and ED on-call are responsible for billable hours.

Hospital-Wide Responsibility:

Works within legal, regulatory, accreditation and ethical practice standards relevant to the position and as established by BWH/Partners; follows safe practices required for the position; complies with appropriate BWH and Partners policies and procedures; fulfills any training required by BWH and/or Partners, as appropriate; brings potential matters of non-compliance to the attention of the supervisor or other appropriate hospital staff.

Qualifications