Position Summary:

The palliative care social worker promotes shared decision‐making, helps to reduce fragmented care, and improves the overall patient experience. They use electronic health record to alert to flag when palliative care patients are admitted to the hospital or miss an appointment. They work across teams to coordinate appointments with other teams to ensure all patients have what they need and work to promote palliative care to patients at every turn. They are responsible for promoting psycho‐social support to patients in need of palliative care and outpatient cancer treatment services. They are an active member of the inter‐disciplinary care team, utilizes and promotes cancer care philosophy and approaches. They apply knowledge of psycho‐social care in support of hospital quality improvement initiatives. Use of telemedicine as needed to meet the needs of all patients in both locations.

Education, License & Cert:

Masters of Social Work (MSW) required.

Experience:

Two years post graduate experience as a social worker in an acute care or similar health care setting. Must also successfully complete a 6‐month hospital based orientation process.

Essential Functions:

• Documents patient care in compliance with agency policy & regulatory standards.

• Complies with standard precautions, infection control and safety procedures.

• Honors confidentiality as spelled out by HIPAA Assists other staff to manage their stress of clinical practice in the field.

• Responsible for maintaining statistical records and patient documentation.

• Responsible to communicate with interdisciplinary team relevant psychological information/resources/referrals/to optimize overall treatment plan.

• Acknowledges and instructs in areas of self/patient advocacy.

• Demonstrate ability to access protective services agencies and police to report abuse cases, and follow‐ups with an accurate and timely written report.

• Fosters coping and adaptation to patient diagnosis and its effects to help patients maintain or improve quality of life.

• Mobilizes new or existing family, clinic, and community resources to provide social and emotional support patients and their families.

• Acts as liaison between Guthrie and other health care providers of the community including physicians, hospital oncology team(s), discharge planning, providers of contract care, and other community resources as appropriate.

• Assesses special needs related to cultural diversity including communication, space, role of family members, special traditions, especially those related to illness or end of life.

• Assists patients and families with end-of-life issues, decisions, planning and advanced directives Coordinates patient palliative care and collaborates with all other team disciplines in all care settings.

• Assists patient/family in accessing financial resources, when necessary, i.e., charity care or patient care funds. Identifies obstacles to compliance; assists in understanding goals of care.

• Involves patient and/or family in treatment plan.

• Assists to meet financial, transportation, lodging and other needs.

• Uses broad range of therapeutic and other interventions, including counseling, group work and education to address patient and family needs in each phase of the illness, offering episodic individual and family counseling, support, community resource planning and crisis intervention when necessary.

• Functions as liaison between all disciplines and volunteers, providing care as necessary to maintain patient/family wellbeing.

• Assists other team members in understanding social, ethical and emotional factors related to health problems. Attends team meetings for the operational and administrative functions of the patient services.

Other Duties:

• Participates in effective interdisciplinary care coordination, identification of problems, development in plan of care, adherence to plan and alterations and facilitates discharge planning when appropriate.

• Identifies and utilizes appropriate community resources.

• Assesses patient and family ability to access services.

• Works in collaboration with inpatient or outpatient care coordinators, community hospice resources or facilities, chaplains, others as needed.

• Facilitates, arranges, coordinates, compassionate, compliant, supportive services and equipment.

• Participates within cancer committee team and relevant subcommittees as appropriate.

• Coordinates educational and outreach services relevant to the social service ‐palliative care interface.

• Records in timely manner evaluation data, progress notes and interventions with patient/family and their responses in electronic medical record.

• Meets all regulatory requirements of the MSW role Participates in palliative care service program development and education tools for healthcare providers and other staff relevant to palliative care.

• Participates in palliative care quality improvement initiatives Assists the palliative care team and/or directly facilitates patient‐family meetings for goal setting and care planning.

• Identifies high risk patients through interaction with staff, providers, patient self‐referral, and attendance at tumor boards.

• Pending accreditation (Corning Hospital Cancer Treatment Center), attends tumor boards weekly and other treatment conferences as appropriate Works with hospital social workers when cancer center patients are hospitalized.

Pay range min $22/hr max $35/hr

Joining the Guthrie team allows you to become a part of a tradition of excellence in health care. In all areas and at all levels of Guthrie, you’ll find staff members who have committed themselves to serving the community.

The Guthrie Clinic is an Equal Opportunity Employer that welcomes and encourages diversity in the workplace.

The Guthrie Clinic is a non-profit, integrated, practicing physician-led organization in the Twin Tiers of New York and Pennsylvania. Our multi-specialty group practice of more than 500 physicians and 302 advanced practice providers offers 47 specialties through a regional office network providing primary and specialty care in 22 communities. Guthrie Medical Education Programs include General Surgery, Internal Medicine, Emergency Medicine, Family Medicine, Anesthesiology and Orthopedic Surgery Residency, as well as Cardiovascular, Gastroenterology and Pulmonary Critical Care Fellowship programs. Guthrie is also a clinical campus for the Geisinger Commonwealth School of Medicine.