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
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
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
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
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.
PRINCIPAL DUTIES AND RESPONSIBILITIES
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
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
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
Facilitates the appropriate and efficient use of hospital and
Participates in formal and informal clinical case reviews,
clinical supervision, educational seminars and research
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
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
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
Participates in data collection for departmental quality
assessment activities in collaboration with the care coordination
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
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.
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
Attends and participates in Staff Meetings and interdisciplinary
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
Meets Department productivity and standards. Ambulatory staff,
ED and ED on-call are responsible for billable hours.
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
Education: Master's of Social Work Degree from an accredited
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
- Cultural sensitivity and demonstrated competency in age
- Knowledge of specific medical/psychiatric illnesses, procedures
- 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
- 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
- Tolerance for ambiguity; analytical skills and computer
- A sense of humor
WORKING CONDITIONS/PHYSICAL REQUIREMENTS
- Social Workers provide clinical care in various settings: at
the bedside, in treatment areas and offices; and in patient's
- 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
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.