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Licensed Clinical Social Worker LCSW Licensed Master Social Worker

Aachele Home Nursing Services LLC
3 hours ago
Full-time
On-site
DeKalb County, Georgia, United States
Master's
Licensed Clinical Social Worker (LCSW) / Licensed Master Social Worker (LMSW)

Responsibilities of the Hospice Licensed Clinical Social Worker (LCSW) or Licensed Master Social Worker (LMSW)

The Hospice Licensed Clinical Social Worker (LCSW) or Licensed Master Social Worker (LMSW) shall participate in the monthly review of dashboard measures affecting psychosocial care, caregiver support, patient access, discharge planning, and care coordination.

Responsibilities include:

  •  Participate as a member of the Interdisciplinary Group (IDG). 
  •  Assess psychosocial needs that may contribute to emergency department visits, hospitalizations, caregiver crisis, or live discharges. 
  •  Assist patients and families with advance care planning and end-of-life decision-making. 
  •  Coordinate community resources to reduce avoidable hospital utilization. 
  •  Participate in actively dying pathway reviews. 
  •  Prioritize visits for patients identified as imminent or actively dying. 
  •  Document patient or family refusals of social work services. 
  •  Participate in reviews of live discharges and seven-day hospice returns. 
  •  Identify psychosocial barriers contributing to emergency utilization, revocations, caregiver burnout, or delayed hospice interventions. 
  •  Participate in root cause analyses and QAPI Performance Improvement Projects when psychosocial factors contribute to unfavorable dashboard measures. 
  •  Collaborate with nursing, physicians, chaplains, and other IDG members to improve patient outcomes. 
  •  Ensure documentation supports psychosocial assessments, interventions, care coordination, and patient/family education. 
Add Under "Final-Days Visits"

The Hospice Licensed Clinical Social Worker (LCSW) or Licensed Master Social Worker (LMSW) shall participate in identifying patients approaching the end of life and prioritize psychosocial visits based upon patient and family needs.

Reviews shall include:

  •  Social work visits completed 
  •  Declined social work visits 
  •  Caregiver distress 
  •  Bereavement risk 
  •  Family education 
  •  Goals-of-care discussions 
  •  Advance directive support 
  •  Emotional and psychosocial interventions 
  •  Coordination with nursing and chaplain services 
Add Under "Live Discharge Review"

The Hospice Licensed Clinical Social Worker (LCSW) or Licensed Master Social Worker (LMSW) shall participate in the review of all live discharges.

The review shall include:

  •  Psychosocial factors contributing to discharge 
  •  Caregiver burnout 
  •  Financial or placement concerns 
  •  Patient goals 
  •  Revocation counseling 
  •  Community resource referrals 
  •  Family education 
  •  Opportunities to prevent avoidable live discharges 
Add Under "Seven-Day Return Review"

The Hospice Licensed Clinical Social Worker (LCSW) or Licensed Master Social Worker (LMSW) shall participate in the review of patients returning to hospice within seven calendar days following a live discharge.

The review shall determine whether psychosocial, caregiver, placement, or resource issues contributed to the patient's return and identify opportunities to improve discharge planning and continuity of care.

Add Under "Weekend Coverage"

Weekend scheduling shall include consideration of psychosocial needs.

When clinically appropriate, the Hospice Licensed Clinical Social Worker (LCSW) or Licensed Master Social Worker (LMSW) may provide weekend visits for patients and families experiencing:

  •  Imminent death 
  •  Caregiver crisis 
  •  Emotional distress 
  •  Placement issues 
  •  Complex family dynamics 
  •  High bereavement risk 
  •  Resource or safety concerns 
  •  Other psychosocial needs identified by the IDG