Social Worker - Home Health or Hospice

Location Address:8100 Constitution Pl NE Albuquerque, NM 87110-7643Compensation Pay RangeMinimum Offer $54,516.80 Maximum Offer $83,262.40SummaryIf you're passionate about making a meaningful impact during critical moments in patients’ lives and have strong expertise in psychosocial care, this is your opportunity to join a compassionate, collaborative team. Apply today to help deliver vital support and improve outcomes for patients and families in need.How You Grow, Learn And Thrive Matters Here. Educational and career development options, including tuition and certification reimbursement, scholarship opportunities Staff Safety (a wearable badge that allows nurses to quickly and discreetly call for help when safety is a concern) Differentials for night/weekend shifts, higher education, certifications and various lead roles (for eligible positions) Malpractice liability insurance Loan forgiveness through the  New Mexico Higher Education Department  EPIC electronic charting systemType of Opportunity: Full time FTE: 1.00 Job Exempt: Yes Work Shift: Days (United States of America)ResponsibilitiesThis role is eligible for sign on and relocation benefits! The Home Health or Hospice Social Worker is responsible for the development, planning, implementation and evaluation of psycho/social interventions for patients followed in the Home and Transition Services programs. This position will be responsible for identifying patients who have complex psychosocial needs, require assistance with eligibility determination for social programs and funding sources and who may qualify for community assistance from a variety of special funds and agencies. In addition, the Hospice/Palliative Care Social worker operates as the mental health professional of the team. All interventions are aimed to improve QOC/Life and decrease complications and readmissions. The HPSW offers crisis intervention to patients and families with psychosocial needs and coordinates and facilitates the development of a plan of care for all patient populations. This role will receive referrals, and consults for patients from at risk populations from interdisciplinary team members (including physicians, Case Managers, staff nurses and other members of the care team) in addition to case finding. Social work interventions and services may be assigned via phone and/or via telehealth means.Additional Job DutiesProvides Hospice/Palliative Social Work across the outpatient and inpatient settings.On the basis of referral, consultation or case finding assesses patients and family s psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope. Completes Psychosocial assessment and provides psychosocial interventions.Manages with the IDT the patient plan of care. Provides strengths-based person and family center of care.Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability. Provides psychoeducation.Provides supportive counseling to patients / families experiencing and/or anticipating issues to adjusting to illness, catastrophic diagnosis, changes in living situations and bereavement.Intervenes with patients demonstrating complicated grief and explores bereavement related to possible death and multiple aspects of loss and adaption along the continuum of care. Provide anticipatory guidance.Provides non-pharmalogical pain and symptommanagent, reinforces patient and family personhood and coping as they negotiate complications with chronic illness and end of life.Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the health care system.Facilitates family meetings. Participates in discharge planning activities in collaboration with other staff for patients, in order to ensure a timely discharge and to provide appropriate linkage with post-acute providers.Provides clinical guidance and consultation to interdisciplinary primary teams, including social workers, and case managers, prompting continuity of care as well as safe and comprehensive care coordination and discharge planning as indicated.Works with families exhibiting complex family dynamics that impact directly on patient care and discharge.Educates patient/family and physician regarding post-acute options and addresses issues of choice.Actively participates and provides pertinent information in complex rounds discharge planning huddles, unit daily whiteboard rounds.Provides intervention in child abuse/neglect, domestic violence, guardianship (temporary/ permanent), foster care, adoption, mental health placement, advance directives, adult/elderly abuse, child protection and sexual assault.Mentors SW master level students.Participates in on call rotation.All other responsibilities as assigned by SW manager.Clinical Judgment and Action: Uses clinical reasoning, which includes clinical decision-making, critical thinking, and a global grasp of the patient care situation, along with the IDT through a process of integrating formal and informal experiential knowledge and evidence-based guidelines to manage patient care.Critical Elements of Clinical Judgment and Action PerformanceConsistently uses the SW assessment to structure and revise careAnticipates, recognizes, and responds to changes in conditionAccurately communicates with healthcare team members to relay changes in patient statusConsistently provides care based upon need and urgencyConsistently applies patient safety principlesDevelops, plans, and evaluate patient short- and long-term care goals. Charts problems plans and goals appropriately in the patient record.Consistently follows policies, procedures, standing order sets, care bundles, core measure practicesConsistently follows red rules: Patient identification and handwashingSeeks consultation if uncertain on how to respond to patient needsAdjusts care to establish and support care goalsIntegrates technology into daily care of patient by appropriate initiation of technology, maintenance, troubleshooting, and discontinuationConsistently and accurately documents care per policies & standardsPatient Advocacy: Works on behalf of the patient/family representing their concerns and helps resolve ethical and clinical issues that impact the patient situation.Critical Elements of Patient Advocacy PerformanceMaintains patient confidentiality/personal/medical informationIdentifies ethical and clinical issuesActs with integrated healthcare team using appropriate resources to resolve ethical/clinical issuesAdvocates for patient needs, values, and goalsCompliance with JC Rights and responsibilities of the Individual elementsClinical Inquiry: Uses high standards and evidence-based practices along with questioning, research and evaluation skills to provide informed and/or change practiceCritical Elements of Clinical Inquiry PerformanceSupports process/quality improvement initiatives and incorporation into practiceFollows and is informed on Department outcome measuresActively participates in changes in practice/roll outsSeeks advice and consultation on care from colleagues and interdisciplinary teamCollaboration: Involves multidisciplinary team as well as patient/family to promote optimal and realistic goals and outcomesCritical Elements of Collaboration PerformanceProvides and coordinates independent, interdependent, and dependent care interventions with interdisciplinary care teamSelects appropriate Screenings from HED to facilitate interdisciplinary care when neededAppropriately delegates care, monitoring delegated team members care and responds as appropriate with the goal of optimizing careInteractions with care team in respectful, professional mannerFacilitation of Learning: Fosters patient/family learning to promote self-care using both formal and informal processes as applicable and at an appropriate level of understanding.Critical Elements of Facilitation of Learning PerformanceSelf: Completes all required learning modules, programs in specified timeSelf: Uses available resources within system to enhance own continuous learningSelf: sets and achieves learning and performance goals yearlySelf: Consults, teaches, supports continuous learning with colleaguesSelf: Actively seeks learning/mentorshipPatient: Assess patient's learning style, readiness to learn, challenges to learning and adapts patient education to meet needsPatient: Incorporates patient in learning about diagnosis(es), care management, medications using appropriate verbal and written communication tools/resourcesResponse to Diversity: Uses holistic body, mind, spirit approach in provision of care by recognizing, appreciating, and incorporating cultural, spiritual, gender, race, ethnicity, lifestyle, socioeconomic, age, and value differences in practice.Critical Elements of Response to Diversity PerformanceProvides communication/ medical interpretation services for population served based upon language preferenceConsistently provides care to population served with appreciation to diversity elements as designated aboveConsistently communicates and documents patient diversity needsUses PHS established internal resources and vendorsSystem Thinking: Manages environmental and system resources across the healthcare system and community to meet patient/family needs or provision of quality care.Critical Elements of Systems Thinking PerformanceUtilizes internal and PHS resources to provide evidence-based care including policy, protocols, procedures, approved specialty resourcesIncorporates all patient safety technology, tools, protocols, communications, and initiatives to optimize a safe patient environmentDeploy in the clinical environment processes to enhance care efficiency, cost containmentPlan, maneuver, and deliver services/technology that are available within the system to meet the care needs of the patientNegotiates within the system to achieve the care needs of the patientFunctioning as an Effective Contingent MemberQualificationsMaster’s degree in social work required.Current license from the State of New Mexico as a Licensed Independent Social Worker-LISW, Licensed Clinical Social Worker-LCSW, or Licensed Master Social Work-LMSW.A license with ten years of hospital social work or discharge planning experience in a relevant setting is required.Licensed Master Social Work License (LMSW) preferred.National Case Management certification preferred.Current Drivers License and InsuranceWe're All About Well-being, Starting With Yours.Presbyterian employees have access to a fun, engaging and unique wellness program, including free on-site and community-based gyms, nutrition coaching and classes, mindfulness and meditation resources, wellness challenges and more.About Presbyterian Healthcare ServicesLearn more about our employee benefits.Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.Compensation DisclaimerThe compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.We're Determined to Support New Mexico's Well-Being | Presbyterian Healthcare Services