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Palliative care Social Worker / LICSW / 40 Hours / BWH care Coordination

Company: Brigham and Women's Hospital
Location: Boston
Posted on: June 12, 2021

Job Description:


The Palliative Care Social Worker will be a part of the BWH Palliative Care Renal Program, Kidney Pal, which provides palliative care to patients with kidney disease across the care continuum, including in-patient, out-patient and dialysis settings. The BWH Kidney Pal team is interprofessional and includes an experienced palliative care social worker, palliative care nurse practitioner and palliative care physician. The Kidney Pal Program is a collaboration between the Departments of Psychosocial Oncology and Palliative Care, and Care Continuum Management at Brigham and Women's Hospital.

The Palliative Care Social Worker is a key member of the interprofessional team, providing and overseeing the provision of palliative care, and, in particular, psychosocial interventions for selected patients and families. Some of the core tasks include: identifying psychosocial and emotional factors that impact the health status of patients/families; formal and informal teaching and modeling the role of palliative care in the course of serious illness; and practicing effective communication strategies to elicit and document patients' values and goals to inform health-related decisions. The Palliative Care Social Worker provides clinical services to patients/families that address environmental, age-specific and cultural issues to maximize emotional, social and physical well-being and effective use of health care and community resources. The Palliative Care Social Worker collaborates with the medical team and provides social work consultation within the hospital and community during care transitions to increase continuity when patients are most vulnerable.

The Palliative Care Social Worker is an effective interprofessional team member and is attuned to team dynamics. Core tasks to promote teamwork include: participation in, contribution to, and implementation of processes to support team cohesion and sustainability. The BWH Kidney Pal Social Worker will participate regularly in team meetings and contribute to program planning, implementation, and evaluation, as well as presentations in both clinical and other, broader settings. The Palliative Care Social Worker will ensure documentation of patients' values and goals and will facilitate referrals to appropriate clinical care teams within the hospital during admissions, as well as across care transitions.

Twenty percent (20%) of this full-time position will be dedicated to program development, measurement and education. Working closely with the Kidney Pal team, the Palliative Care Social Worker will represent, advocate, and teach other clinicians the psychosocial, emotional and spiritual needs of this patient population.

The Clinical Social Worker reports directly to the Manager, Palliative Care Social Work, Dept. of Care Continuum Management. The Clinical Social Worker will be provided mentoring by the Kidney Pal interprofessional team and will have opportunities to collaborate with other palliative care social workers.


Clinical Practice:

Provides assessment of patients to evaluate mental health/psychiatric history/emotional issues/coping style, understanding of illness/adjustment/compliance, barriers to care, cultural issues, abuse/neglect and domestic violence.

Provides psychosocial assessment of families to determine family relationships/systems as they relate to care of the patient. Identifies family decision makers and caregivers; family understanding of illness and trajectory of care. Identifies family coping style, family resources and cultural issues.

Employs a range of clinical interventions such as individual, group or family counseling. Provides caregiver/family counseling/support to promote family cohesiveness to provide care to patient and prepare families for end of life. Advocates on behalf of patients and families to gain access to services and resources. Refers patients to other providers, as necessary.

Develops comprehensive bio-psychosocial assessments responsive to age appropriate and cultural needs and concerns. Employs a range of clinical interventions such as psychotherapy (individual, couples, families, and group), psychosocial counseling, crisis intervention, care coordination, complementary therapies, information and referral and safety planning. Advocates on behalf of patients and families to gain access to services and resources.

Provides mandated assessments when abuse is suspected (child, disabled adult, elder) and safety assessment when domestic violence is reported. Files reports as indicated.

Identifies patients' psychosocial, financial, legal, psychiatric or substance use that effect patient care management and collaborates with the team to facilitate patient care process.

Works effectively as part of the interdisciplinary health care team, communicating regularly with the team and other members on cases and as issues arise. Documents timely and relevant information.

Coordinates family/team meetings, as needed and when appropriate. Provides psychosocial consultation on patient care planning and patient/family management and community resources. Implements psychosocial programs based on patient/family identified needs.

Facilitates the appropriate and efficient use of hospital and community resources.

Participates in formal and informal clinical case reviews, clinical supervision, educational seminars and research projects.

Quality, Utilization Management: High Risk Psychosocial:

Intervenes with appropriate individuals/departments/agencies regarding delays in service that may have an impact on quality of patient care, length of stay or inappropriate patient admissions.

Reviews patient information for assigned caseload, determines anticipated length of stay and psychosocial barriers to plan of care transitions discharge plan in collaboration with the Nurse Care Coordinator

Interacts with home care, community agencies and facilities to ensure safe and timely patient care transitions

Negotiates with care coordination team followup contact with patient/family, community agency or facility to evaluate the effectiveness of the patient care transitions and identifies problems in service delivery

Ensures coordination of the communication process with patient/family concerning the plan of care, including coordination of family meetings and warm handoffs.

Ensures that patient/family is involved in all phases of the care process to the greatest extent possible.

Maintains current knowledge of and identifies needs in service delivery within social, governmental, protective services and legal agencies.

Participates in data collection for departmental quality assessment activities in collaboration with the care coordination department.

Participates in quality assessment/improvement activities designed to evaluate the appropriateness and effectiveness of the service delivery system in which care coordination operates.

Ensures that the patient and family receive consistent information regarding all aspects of care.

Communicates and collaborates with the Social Work Manager/Team to ensure efficient and quality patient care and equitable caseloads.

Leadership, Teaching and Education:

Assesses patient/family learning needs, styles and readiness. Educates patients/families based on treatment plan, identifies barriers to care, diversity issues and learning styles.

Mentors and may supervise students and staff. May teach in Departmental and Hospital seminars, workshops and rounds.

Demonstrates expert social work clinical practice within the department and with interdisciplinary staff. Provides education and consultation to interdisciplinary health care providers, social work staff and community on psychosocial issues for patients.

Demonstrates active, ongoing commitment to professional growth and development of self and creates an environment conducive to the professional growth of others.

Participates in Departmental and Hospital committees. May participate in social work research.

Organizational/Administrative Skills:

Takes responsibility for own administrative duties, including timely and appropriate documentation in patient medical records, timely and accurate daily reporting of activities and Hospital's scheduling systems, and accurate reporting of time worked.

Provides clinical documentation including psychosocial assessment, progress notes, and billing compliance (if appropriate).

Attends and participates in Staff Meetings and interdisciplinary meetings/rounds.

Professional Conduct:

Adheres to and fosters compliance with NASW Code of Ethics, and Department and Hospital clinical, quality, compliance and safety standards, policies and procedures.


Expected to mentor, precept, teach social workers and social work residents


Meets Department productivity and standards. Ambulatory staff, ED and ED on-call are responsible for billable hours.

Hospital-Wide Responsibility:

Works within legal, regulatory, accreditation and ethical practice standards relevant to the position and as established by BWH/Partners; follows safe practices required for the position; complies with appropriate BWH and Partners policies and procedures; fulfills any training required by BWH and/or Partners, as appropriate; brings potential matters of non-compliance to the attention of the supervisor or other appropriate hospital staff.


Education: Master's of Social Work Degree from an accredited program required.

Licensure: Current Massachusetts Licensed Independent Clinical Social Worker (LICSW) required.

Experience: Previous clinical social work experience in a hospital setting preferred.

Bilingual (English/Spanish) preferred.


  • Clinical experience, understanding of, and comfort working with patients of all ages who suffer complex medical and psychiatric problems; ability to work with the families of such patients, and ability to help patients and families understand and access the resources required to support care.
  • Ability to provide rapid clinical psychosocial assessments and brief, short or long term treatment/management with individuals, families, couples and/or groups.
  • Advanced crisis intervention/treatment/management skills; strong assessment and treatment skills.
  • Differential diagnosis and treatment with all modalities
  • Competence in abuse/neglect/violence, trauma, grief loss and bereavement
  • Cultural sensitivity and demonstrated competency in age specific behaviors
  • Knowledge of specific medical/psychiatric illnesses, procedures and treatments
  • Excellent clinical social work assessment and crisis intervention knowledge and skills
  • Strong understanding of psychiatric and family system problems, and ability to use this understanding to formulate succinct case summaries.
  • Knowledge of community agencies/resources. Ability to advocate/negotiate systems for/with patients and families.
  • Demonstrated ability to understand the role of social worker in a complex, fast-paced medical environment
  • Demonstrated ability to consult/teach
  • Demonstrated ability to communicate effective orally and in writing. Excellent interpersonal skills including negotiation skills necessary to collaborate within a multi-disciplinary team.
  • Tolerance for ambiguity; analytical skills and computer literacy
  • A sense of humor


  • Social Workers provide clinical care in various settings: at the bedside, in treatment areas and offices; and in patient's homes.
  • The Department of Care Coordination /Social Work will operate 7 days per week. Hours and work schedule will be flexible to meet the needs of patients, families, hospital and staff.
  • Must be prepared to come in to work or stay at work during a hospital emergency.

Patient Population:

Staff member must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served on his/her assigned areas.

Keywords: Brigham and Women's Hospital, Boston , Palliative care Social Worker / LICSW / 40 Hours / BWH care Coordination, Other , Boston, Massachusetts

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