Northern Light Home Care and Hospice Department: Home Health - Ellsworth Position is located: Northern Light Home Care and Hospice Ellsworth Work Type: Full Time Hours Per Week: 36.00 Work Schedule: 8:00 AM to 5:00 PM Summary: The Licensed Master Social Worker functions within their scope of practice as a member of a multidisciplinary team, including the patient/family, physicians, nurses, pastoral care, hospice services, care management, and therapists in the Palliative Care Program. The Licensed Master Social Worker serves as patient advocate and liaison between the hospital, facility and community providers, resources, and agencies, working collaboratively, to ensure seamless transitions across the continuum of care for patients and families. Additionally, the Licensed Master Social Worker supports initiatives focused on Community and Provider education, and preventing readmission when aligned with patients’ goals of care. The Licensed Master Social Worker seeks to resolve psychosocial patient care issues, provide support and counseling for those with serious, life-limiting illness,( including bereavement and anticipatory guidance for dying patients), provide support with identification of goals of care and decision-making, and assists in developing complex patient transition/discharge plans as needed. The Licensed Master Social Worker also provides assistance to patients, families and others with a wide variety of needs to include, but not limited to, financial concerns and/or emotional problems related to the impact of illness and disease burden. Provides supportive counseling to patients regarding adjustments to illness as well as other psychosocial needs as indicated. The incumbent performs duties and tasks in accordance with performance standards established for the job. The incumbent is responsible for participation in and completion of all patient safety initiatives appropriate to the position. In addition, the incumbent conducts all job responsibilities according to the Mission and Values of Home Care & Hospice/ EMHS. Responsibilities: Clinical Practice- Works in conjunction with providers and others to assess, plan and initiate patient plan of care for patients with serious and life-limiting illness, including initial and ongoing Palliative Care consultations. Provides psychosocial assessments of the patients and families in relation to the crises of acute and chronic illness. • Initiates a systematic, accurate and ongoing comprehensive assessment of needs of the client, family, and/or significant other. • Meets with patients and families to provide psychosocial support and address goals of care. • Obtains, interprets, and communicates necessary information regarding patients and families, including social history information, to Palliative Care team, and physicians. • Arranges and participates in care conferences with appropriate patient care staff, including but not limited to Palliative Care, Hospice, Home health, Beacon, PCP/specialty practices, in-patient staff (Hospital /SNF/LTC) and patients and families. • Consults with patients to determine psychosocial concerns and clarify goals of care. • Meets with family to explore caregiving concerns. • Reviews medical records/nurse assessment forms for further insight into patients’ needs. • Demonstrates competency in the fundamentals of case management. • Develops and implements appropriate treatment plans and interventions in collaboration with primary, referring providers. • Utilizes crisis interventions to mobilize resources in response to crises. • Counsels and supports individual, families to help adjust and cope with illness. • Make referrals to appropriate community resources. • Initiates actions directed toward achieving expected outcomes. • Collaborates with others to evaluate and modify the POC based on client outcomes. • Exercises independent judgment in supervising and directing client care provided by other members of the client care team, with accountability if such care is not rendered accurately or appropriately. • Adheres to discipline specific clinical practice standards. • Acknowledges the value of and participates in the interdisciplinary team meetings and utilizes services according to standards of care. • Provides service and produces work at or above expected levels of quality and consistent with agency defined quantitative standards. • Documents accurately, completely and in accordance with Agency policy. • Demonstrates knowledge, skills, and abilities necessary to provide care to the age groups served. Community Outreach- Serves as a resource to physicians and in-patient personnel regarding available agency, facility, and community services to assist in planning for Palliative Care patients and provision of ongoing education and support. • Develops and maintains good working relationships with outside community health and social agencies. Works as a member of the Palliative Care service line in reaching out to the community to develop new resources for meeting patient needs. • Participates in the provision of outreach education to Providers, community members, and others as directed as part of the EMHS Palliative Care service line. Other Information: Current license to drive in the state of Maine, with reliable transportation and agency required auto liability insurance. Must be able to travel within assigned region, or statewide, depending on the position. Competencies and Skills + Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan. + Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of diversity, inclusion, empowerment and cooperation. + Demonstrates Adaptability: Learns quickly when facing a new problem or unfamiliar task; is flexible in their approach with changing priorities and ambiguity. Manages change effectively and does not give up during adversity. Capable of changing one's behavioral style and/or views in order to attain a goal. Absorbs new information readily and puts it into practice effectively. + Demonstrates Emotional Intelligence: Exhibits a high level of self-awareness, self-management, other awareness and relationship management. Conducts themselves in an empathic, appropriate way, with a sense of humor and stimulates a collaborative work environment. Is respectful of the attitudes, feelings, or circumstances of others and aware of the influence of their own behavior on them. Is aware of relevant social, political, system, and professional trends and developments and uses this information for the organization's benefit. + Develops Self and Others:Takes responsibility for engaging in professional self-development activities and programs. Strives to gain insight into their own values, strengths and weaknesses, interests and ambitions and takes action in order to enhance competencies and skills when possible. As a leader, encourages and guides employees towards growth opportunities to enhance performance and help them reach goals. Reviews and analyzes employees' strengths and weaknesses to distinguish their talents and development needs, and to ensure they are enhanced appropriately. + Effectively Communicates: Listens, speaks and writes appropriately, using clear language. Communication methods are fitting to the message(s), audience, and situation and follow-ups are regular and timely. Shows that important (non-) verbal information is absorbed and understood and asks further questions to clarify when necessary. Expresses ideas and views clearly to others and has ability to adjust use of language to the audiences' level. + Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved. + Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others. + Provides Patient-Centered Care: Demonstrates understanding of patient care quality and service as organizational priority. Proactively supports change to improve patient experience and results. Exhibits the ability and willingness to find out what the patient wants and needs and to act accordingly, taking the organizational and outside resources into account. Cooperates, collaborates, communicates, and integrates care within and between teams to ensure that care is continuous and reliable. Credentials + LSW, LMSW-CC, and LCSW Working Conditions + Potential exposure to abusive and/or aggressive people. + Potential exposure to diseases or infections. + Need to drive to perform responsible duties. + Potential exposure to hazardous materials. + Potential exposure to noise levels being uncomfortable. + Potential exposure to noxious odors. + Potential exposure to very hot or cold temperatures. + Work with computers, typing, reading or writing. + Lifting, moving and loading 20 to 30 pounds. + Prolonged periods of sitting. + Alternate shift schedules (day, evening, nights, weekends). + Prolonged periods of standing. + Prolonged periods of walking. Position Social Worker/LMSW-CCLocation Req ID null