Social Worker, Palliative Care at Home - (Mount Sinai Home Health) Full Time - Day

Palliative Care at Home provides home based palliative symptom assessment, treatment and ongoing goals of care discussions for patients and families facing advanced illness.  The full clinical team is comprised of CHWs, NPs, nurses, social workers and physicians. The team works in collaboration with patients’ healthcare teams to provide high-quality evidence based complex palliative care and chronic care management and is designed to improve symptoms and QOL, reduce caregiver burden, reduce unnecessary inpatient utilization, and facilitate hospice when appropriate. Social Worker assesses psychosocial needs/acuity and identifies opportunities for SW intervention based on case finding, patients' needs and referrals from care team.   

DESCRIPTION OF COMPETENCIES

A.   Operational Duties 

• Provides direct social work service to patients and caregivers by providing assistance with social and 
  practical environmental problems. 
• Provides supportive individual and family counselling to reduce anxiety/stress and symptoms precipitated 
  by advanced illness and hospitalizations.  
• Work closely with interdisciplinary team to create and coordinate patient care plans, including comprehensive 
  interdisciplinary plan of care that meets the patient and caregiver needs and address changes in patient 
  symptoms.
• Work closely with the clinical team to help process emotional and psychosocial nature of this work. 
• Educates patient/family on trajectory of illness, use of medications, assesses disease understanding.
• Participate in weekly IDT meeting with care team.
• Excellent teamwork, communication and leadership skills.
• Documentation as required.
• Performs other related duties as assigned.
   

Required: 

• Master’s degree in Social Work from a CSWE accredited social work program 
• Licensed as a LMSW or LCSW in NY 
• Palliative care/hospice experience
• Experience working in interdisciplinary care teams 
  Preferred: 
• Hospice and Palliative Certification 
• Chronic illness management experience
• Spanish speaking proficiency/fluency