The Home Services Social Worker identifies the psychosocial needs of patients and families through assessment. Social work interventions range from resource support identification and acquisition (including community support, financial and environmental enhancement) to short term counseling and emergent crisis intervention. Social Services are provided as part of a collaboration with interdisciplinary teams. Hours may vary depending upon census and program need. Provide psychosocial assessments of patients and families to identify emotional, social, and environmental strengths and problems related to their diagnosis, illness, treatment, and/or life situation. Captures all legitimate revenue; conservative in expense and resource use yet provides appropriate service and supplies to patients. Develops a bereavement plan of care to address family member/care giver needs. Interprets and communicates pt/family faith and culture traditions. Identifies and communicates when spiritual/religious beliefs may impact the physical and psychosocial care provided by other team members. Documents recert and discharge assessments which accurately reflect change in patients status and declines/improvements realized in comparison with initial assessment elements. Educates patient and family members in a manner that overcomes barriers; matches their learning capabilities and meets fundamental needs. Investigates and applies payer specific Commercial Hospice Benefits to optimize treatment opportunities. Visit notes and orders are completed and transmitted in a timely manner according to policy. Corrections to care plans are entered and transmitted according to time line. Documents psychosocial patient/family assessments, financial assessment and MSW interventions within patients' electronic medical record. Implements social work plan that results in: a) enhanced strength of family systems, b) patient/family/caregiver utilization of community resources, c) maximization of medical benefits, d) enhanced environment for care delivery, e) dignity for the dying patient, f) maximized patient/family coping skills, g) support for patient/family cultural beliefs and values. Evaluates effectiveness of social work plan of care and modifies intervention as indicated. Facilitates and supports patient decisions and communication of self-determined life care decisions. Provides care according to plan of care/orders. Develops social work plan of care in collaboration with IDT. Practices in a manner sensitive to the needs of patients and families. Daily practice and documentation are evidence of understanding of palliative/comfort philosophy and approach (versus aggressive/curative treatment). Identifies and responds to indicators of imminent death, addresses patient/family needs at time of death. Demonstrates understanding of Medicare Hospice Benefit including benefit eligibility, qualification for admission, election process, certification, recertification, transfer, non-recertification and revocation. Utilizes Memorial Funds appropriately and submits documentation in a timely manner according to policy. Demonstrates understanding of Medicare Home Care benefit including eligibility, qualification for admission and services available. Complete or assist and educate the patients/caregivers on advanced directives, including living will, HCPOA, and POLST forms. Assist with Transportation barriers Assistance with Referrals for lack of access to food, clothing, assistance with power bills Make referrals for help in the Home Assistance with Applications (Medicaid, Community Care, SSDI) Make Elder Abuse/Neglect Referrals