Job Description

The Social Worker assigned to the PRN Inpatient Palliative Care Program will provide comprehensive psychosocial services to all members/families receiving an IPC consult. The Social Worker will be a part of the interdisciplinary Palliative Care team and will be responsible for assessing, planning and coordinating the social services and community resources necessary to respond to the patient's health care needs and wishes. In addition, responsibilities will include 1) interacting with practitioners, members/families, IPC program staff, vendors and other Kaiser Permanente and QRM staff, 2) education of practitioners, member/family and others, 3) discussing end of life planning with patient and family and support the end of life decision making process, 4) assisting in completing end of life documents, 5) exploring family conflict and supporting emotional issues, 6) coaching family/patient on how to talk about difficult issues, 7) educating patient/family on disease and caregiving issues, 8) ensuring that legal, financial and health care planning take place, 9) providing linkages to community resources and services including hospice, 10) monitoring quality of care, and 11) promotion of high level of member satisfaction.

Major Responsibilities/Essential Functions:

1. Performs functional, psychosocial and financial assessments of the member/family as part of the initial screening. This will be done through the use of provider and hospital records, contact with the member/family, significant others, caregivers and current medical caregivers (if permitted by member).
2. Speak with the case manager or other team members regarding the patient's current psychosocial and/or discharge planning needs/issues.
3. Shares important psychosocial issues/or concerns with the team prior to consult.
4. As part of the consult, the social worker will 1) facilitate introductions of team members and explain "palliative care" to the patient/family, 2) review the purpose of the meeting with the patient/family, 3) assess and validate patient/family experience and offer psychological/emotional support, provide desired information regarding benefits and potentially available resources,4) provide the wrap-up of the meeting and reiterate what the patient/family can expect for follow-up according to identified needs.
5. Will assist IPCCs in problem solving and difficult cases for IPC patients.
6. Works closely with the inter-disciplinary team to facilitate care services to IPC patients
7. Provides psychosocial assessment and acts as an advocate for the patients psychological, social and spiritual needs.
8. Discusses end of life planning with the patient and/or family and supports the end of life decision making process.
9. Assist patient/family in completing the end of life documents.
10. Collaborates with other team members and seeks community services to assist the IPC patient when there is no benefit for specific services that the members may need. Researches and incorporates alternative funding, if appropriate.
11. Communicates with IPCCs/CCM regarding the meeting outcomes and plan for next steps.
12. Make any necessary community referrals.
13. Facilitate follow up meeting as necessary.
14. Collaborates with the team to develop and implement quality guidelines and data collection efforts that measure and improve the IPC program and processes.
15. Supports QI activities by identifying potential quality deviations and provides appropriate information to the QI Manager.
16. Remains knowledgeable of current, relevant state and federal regulations, criteria, documentation requirements and laws that affect managed care and disease care management. Educates staff and physicians on the changes and the implications of the changes. Ensures that policies and procedures are revised and implemented to meet requirements
17. Works cross-functionally with other departments to meet organizational goals and objectives.
18. Knowledgeable and compliant with regional personnel policies and procedures.
19. Knowledgeable and compliant with QRM departmental and unit specific policies and procedures.
20. Participates in annual regional and departmental compliance training.
21. Develops and maintains an awareness of how to report compliance issues and concerns.

Other Responsibilities:

1. Perform other duties as assigned.
2. Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente's Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licensure requirements, and Kaiser Permanente's policies and procedures.
3. Access to protected health information (PHI) will be limited to the minimum necessary required to effectively perform your job.

Minimum Work Experience, Required Lincenses and Education:

• LCSW or LMSW licensure in the state of Georgia
• Valid Georgia driver's license
• At least two (2) years of post-graduate experience in a healthcare setting
• Knowledge of community resources required
• Working knowledge of all federal, state, local and regulatory requirements, including Medicare/CMS

Preferred Work Experience and Qualification:

• Experience in hospice, palliative care or home health environment

The Southeast Permanente Medical Group

Job Tags

Work experience placement, Relief, Local area,

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