Social Worker​/Hospice

Transitions Care is seeking a Social Worker to support hospice patients and families across home and facility settings. In this role, you will complete psychosocial assessments, develop care plans, and provide counseling, crisis intervention, and grief support. You will advocate for patient goals, facilitate advance care planning, and connect families with community resources. Working closely with nurses, physicians, chaplains, and aides, you will ensure compassionate, coordinated care that honors dignity, cultural values, and quality of life at end of life.

Responsibilities

• Conduct comprehensive psychosocial assessments for hospice patients and families
• Develop and update individualized care plans aligned with patient goals and values
• Provide counseling, crisis intervention, and grief and bereavement support
• Facilitate family meetings and advance care planning discussions
• Coordinate community resources, benefits, and support services
• Collaborate with interdisciplinary hospice team members on care planning and delivery
• Advocate for patient rights, preferences, and cultural needs
• Maintain timely, accurate documentation in the electronic medical record
• Educate patients and families on hospice philosophy and available services
• Participate in team meetings, case conferences, and quality improvement initiatives

Required Skills

• Psychosocial assessment
• Care planning
• Crisis intervention
• End-of-life counseling
• Grief and bereavement support
• Interdisciplinary team collaboration
• Community resource coordination
• Documentation and EMR usage
• Patient and family education
• Advance care planning