Client Care
- Accepts referrals and makes timely visits in accordance with licensure and accreditation requirements, under the direction of an MD, and MD/IDG plan of care.
- Completes initial psycho-social assessment and re-assessments identifying problems, developing interventions, visit schedule and strategies and setting goals for treatment with and for patient/family, with consideration and respect for patient wishes.
- Ensures, with other members of the IDG, the palliative focus of care at time of admission to service.
- With other members of IDG, assists family in understanding changes in the patient’s status related to the progression of end-stage disease.
- With other members of the IDG, insures that informed consent, understanding of patient choices for care, and expected outcomes are explained and understood by patient/family.
- With other members of the IDG, informs patient/family about their rights.
- With other members of the IDG, promotes patient acceptance of own strengths and unique qualities.
- With other members of the IDG, assists the patient/family to identify areas of importance in achieving reconciliation and closure with self, family, friends and community.
- Initial and ongoing assessment of the impact of the terminal diagnosis on the patient's and caregiver’s physical, functional, psychosocial, and environmental needs and activities of daily living.
- Provides social work services in accordance with professional standards and the plan of care in consultation with physician, the hospice interdisciplinary team (IDG), and other care team members. Services include: assessment of individual and family needs, family dynamics and communication patterns, caregiver’s ability to function effectively, support systems, obstacles and risk factors that may affect compliance with plan of care, short term individual counseling, crisis intervention, assistance in providing information and preparation of advance directives, assist with planning for long-term care needs, if indicated, funeral planning issues and transfer of responsibilities regarding fiscal, legal, and health care decisions, assessment of risk for pathological grief, assessment of bereavement with referral/follow-up as needed.
- Works with other IDG team members to understand the social and emotional factors related to health problems and additional stressors in family.
- Assess special needs related to cultural diversity including communication space, role of family members, family dynamics, and special traditions.
- Regularly evaluates patient's/family responses to psychosocial interventions.
- Regularly evaluates patient progress, coordinates plans with IDG.
- Participates in development/revisions in Plan of Care and visit frequency with IDG, patient, family, physician and other necessary participants.
- Instructs patient/family and other members of the IDG patient care team in patient's treatment regime when indicated.
- Utilizes and provides patient/family with appropriate community resources as needed.
- Levels of support and nurturing are increased or modified in consideration of patient preferences as death approaches.
- Assists in preparation and support for the patient’s death.
Documentation
- Records the psycho-social assessment, plans and completes visit documentation in agency EMR in in a timely manner (within 24 hours).
- Reports to physician, IDG, and others as needed.
- Initial assessment documentation must be completed within 24 hours of patient assessment. Orders will be completed in the acceptable Agency format and telephone orders must be obtained. The initial assessment must include, but not be limited to:
- medical diagnosis – any pertinent psychiatric conditions
- functional diagnosis
- findings including:
- evaluation of patient’s preferred style of communication, including expressing emotions, feelings, thoughts, and needs.
- evaluation of patient’s mental health needs.
- patient coping including: access to adequate and accurate information, change in family roles, communication ability.
- problem identification
- goal setting (long/short term) in measurable terms (outcome measures)
- treatment/intervention plan
- rehab potential
- physician communication
- assessing suicidal ideation and psychiatric history
- coping strategies and effectiveness
- sexuality and sexual expression
- signs of mistreatment, abuse/neglect, injuries or misappropriation of patient property with appropriate reporting of findings, when indicated
- safety consideration
- substance/medication use/abuse
- caregiver/care provider effectiveness, capacity and coping
- change in family roles
- communication abilities
- Progress notes for every visit to include:
- psycho-social findings
- identified problems
- psycho-social progress, barriers to progress
- Any client/family education given and any home program given
- discharge planning, if indicated
- goals for further sessions in measurable terms (outcome measures).
- Client response to psycho-social intervention
- A ten-day, sixty-day, and discharge summary is completed timely.
- Communication with any member of IDG or patient care team
Referrals
- Identification of patient/family needs for other hospice or home health services and appropriate community resource referrals when needed.
Case Management
- Participates in case conferences, case management, IDG, and other team meetings.