The purpose of this position is to provide initial psychosocial evaluations,
ongoing psychosocial counseling, direct casework services, bereavement services and
community education, outreach and referrals. Responsible for the delivery of varied social work
services to hospice patients and families and actively participate as a member of the hospice
interdisciplinary team.

• Assesses the psychosocial status of patients and families/caregivers related to the patient's terminal
illness and environment and communicates findings to the registered nurse and other members of the
interdisciplinary group. Provides an assessment in the patient's identified residence and assistance
when this is not safe and another plan is required.
• Carries out social evaluations, including family dynamics, caregiver abilities, communication
patterns, high risks for suicide, neglect or abuse and plans intervention based on evaluation findings.
Counsels patient and family/caregivers as needed in relationship to stress, and other identified coping
difficulties. Provides crisis intervention when necessary.
• Assesses for, and educates interdisciplinary group, on any special needs related to the culture of the
patient and family. Includes communication, role of family, space, and any special traditions or
taboos.
• Maintains clinical records on all patients referred to social work.
• Point of Service documentation is an expectation of all clinical personnel for quality care, accuracy,
and communication standards. The clinician is expected to appropriately document at Point of
Service, have timely synchronization of patient data & effectively communicate with the Patient
Care Team.
• Educates patients and families on, and assists in, preparation of advanced directives.
• Provides information and referral services for organization patients and families/caregivers regarding
practical and environmental needs.
• Provides information to patients and families/caregivers and community agencies.
• Serves as liaison between patients and families/caregivers and community agencies.
• Maintains collaborative relationships with organization personnel to support patient care.
• Maintains and develops contracts with public and private agencies as resources for patient and
personnel.
• Participates in the development of the plan of care, involving the patient and family, and attends
regularly scheduled interdisciplinary group meetings, assisting the team in recognizing the effects of
the psychosocial stresses on the symptoms of the terminal illness.
• Assists physician and other team members in understanding significant social and emotional factors
related to health problems and death/dying issues.
• Participates in discharge planning when needed. Assists patient and family/caregiver with securing
durable power of attorney and with funeral arrangements, as needed

• Assists family and patient in planning for funeral arrangements, financial, legal, and health care
decision responsibilities.
• Other duties as assigned.