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The MSW is responsible for the implementation of standards of care for medical social work services provided to hospice patients and their families. Medical Social Workers are core members of the Interdisciplinary Group and provide psychosocial support to the patient/family unit based on the initial and ongoing assessment of needs and identified goals, interventions and services indicated. Services are provided in accordance with the established plan of care and utilize professional training and judgment in monitoring the psychosocial process.

1. Assesses the psychosocial status of patients and families/caregivers related to the patient's terminal illness and environment and communicates findings to the registered nurse and other members of the interdisciplinary group. Provides an assessment in the patient's identified residence and assistance when this is not safe and another plan is required.
2. Carries out social evaluations, including family dynamics, caregiver abilities, communication patterns, high-risks for suicide, neglect or abuse and plans intervention based on evaluation findings. Counsels patient and family/caregivers as needed in relationship to stress, and other identified coping difficulties. Provides crisis intervention when necessary.
3. Assesses for, and educates interdisciplinary group, on any special needs related to the culture of the patient and family. Includes communication, role of family, space, and any special traditions or taboos.
4. Educates patients and families on, and assists in, preparation of advanced directives.
5. Participates in the development of the individualized plan of care, involving the patient and family, and attends regularly scheduled interdisciplinary group meetings, assisting the team in recognizing the effects of the psychosocial stresses on the symptoms of the terminal illness.
6. Assists physician and other team members in understanding significant social and emotional factors related to health problems and death/dying issues.
7. Assists family and patient in planning for funeral arrangements, financial, legal, and health care decision responsibilities.
8. Communicates

1. Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and care given. Records changes/outcomes as appropriate.
2. Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required.
3. Communicates with community health related persons to coordinate the care plan.
4. Provides information and referral services for organization patients and families/caregivers regarding practical and environmental needs.
5. Provides information to patients and families/caregivers and community agencies.
6. Serves as liaison between patients and families/caregivers and community agencies.
7. Maintains collaborative relationships with organization personnel to support patient care.
8. Maintains and develops contracts with public and private agencies as resources for patient and personnel.
9. As a mandatory reporter, reports failure to comply with the requirements of applicable VA state law and ethics to the Virginia Dept. of Health as required within 14 calendar days, using Dept. of Health forms.
10. Reports suspected abandonment, abuse, financial exploitation, or neglect of a person in violation of applicable state law and ethics to the department of social and health services and the proper law enforcement agency. Reports must be submitted immediately when the reporting person has reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred.
11. Teaches the patient and family/caregiver coping techniques as appropriate. Works in concert with the interdisciplinary group.
12. Provides and maintains a safe environment for the patient.
13. Assists the patient and family/caregiver and other team members in providing continuity of care.
14. Works in cooperation with the family/caregiver and hospice interdisciplinary group to meet the emotional needs of the patient and family/caregiver.
15. Attends interdisciplinary group meetings.

1. Participates in on-call duties as defined by the on-call policy.
2. Assists and supports the RN Case Manager to ensure that arrangements for equipment and other necessary items and services are available.
3. Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and in-service classes.
4. Fulfills the obligation of requested and/or accepted case assignments.
5. Actively participates in quality assessment performance improvement teams and activities
6. Other duties as delegated.

The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job related tasks other than those stated in this description.

1. A graduate of a Master’s program in Social Work (MSW) from a school accredited by the Council on Social Work Education
2. Minimum of one (1) year experience in health care, hospice experience preferred. Understands hospice philosophy, and issues of death/dying.
3. Experience in hospice care preferred.
4. Demonstrates good verbal and written communication, and organization skills.
5. Once an offer of employment is made, it is contingent upon satisfactory references, as requested, and criminal background checks by regulation.
6. Prolonged or considerable walking or standing. Visual acuity and hearing to perform required social work skills.
7. Must be a licensed driver with an automobile that is insured in accordance with state/or organization requirements and is in good working order.