Resource Team Social Worker

Agrace; Madison (WI); On-site; USD 52,000 - 72,000; Full time

Benefits offered by this job

Competitive salary with mileage

Health, dental, vision insurance

Retirement plan with employer matching

Generous PTO & holidays

Onboarding, mentorship and career dev.

Job summary

Agrace is seeking a Homecare Social Worker in Madison, Wisconsin to provide patient- and family-centered social work services. You will conduct assessments, craft and update plans of care, and communicate with the interdisciplinary team to ensure quality end-of-life care in the home setting.

You will advocate for patient goals, coordinate transitions, educate families on coping and resources, and document progress in the electronic health record.

Qualifications

• BSW required; MSW preferred.
• Current, unrestricted Social Work license in state of employment.
• Valid driver’s license and access to reliable vehicle.

Responsibilities

• Perform initial and ongoing patient/family psychosocial assessments.
• Develop and update individualized Plan of Care (POC) with the IDT.
• Coordinate transition planning with patient/family and homecare team.
• Provide education and resources to patients and families regarding grief and bereavement.
• Document assessments, interventions, and outcomes in the EHR.
• Act as patient/family advocate to obtain resources and support.

Skills

Communication skills

Confidentiality

Care coordination

Education

BSW (Bachelor of Social Work)

MSW (Master of Social Work)

Tools

Epic

MS Office

Job description

Location: Madison, WIFull-time 1.0 FTE (40hours/week) | Day Shift | Monday-Friday | Hours 8 am - 5 pmMake a lasting impact with AgraceJoin Agrace, a nationally recognized nonprofit leader in hospice and palliative care. If you are a skilled Social Worker who values meaningful, patient-centered care, this is your opportunity to make a difference!How You’ll Make a Difference (Essential Functions)The Homecare Social Worker is responsible for patient and family satisfaction through the provision of direct social work services by conducting assessments, providing interventions, creating and updating the plan of care, communicating, and documenting. The provides patient and family centered care consistent with Agrace philosophy, goals, standards, regulations and policies.Key ResponsibilitiesInitial and Ongoing Patient/Family AssessmentsAssess patient and family psychosocial, spiritual, grief and educational needs as part of the initial and comprehensive as per the patient’s individualized Plan of Care (POC).Advocate for patient/family goals.Coordinate transition planning in collaboration with the patient/family, homecare, and Interdisciplinary Team (IDT).Anticipate and respond to patient/family psychosocial, spiritual, resource, or grief needs. Round on patients.Care Planning and CoordinationCollaborate with IDT and patient/family to formulate, implement, and revise individualized Plan of Care (POC) in the electronic health record (EHR). The POC to include goals, interventions, education, discharge plan, etc.Read, understand, and follow POC. Document education, interventions, and outcomes in EHR.Intervene, document, and report significant changes in condition or unusual incidents to appropriate IDT member such as client abuse/neglect, suicidal intent, harmful coping mechanisms or violence, etc.Facilitate communication among patients, families, and Agrace staff.Education, Intervention, and ResourcesProvide individual patient/family education and support regarding behaviors, emotions, and psychosocial adjustment to terminal illness, dying, and bereavement. Evaluate the effectiveness of education and adjust to meet needs.Provide appropriate education and interventions for patient/family based on clinical assessment and patient/family goals. Evaluate the effectiveness of interventions and adjust to meet needs.Develop and maintain knowledge of community, legal, Agrace, and hospice specific resources. Refer patients/families to resources. Act as patient/family advocate to obtain resources.Assist with Power of Attorney for Health Care (POAHC), Financial Power of Attorney, Living Will, and Guardianship including assistance with POAHC capability and competency assessment.MiscellaneousParticipate in meetings to plan and evaluate patient/family services.Participate in SW on-call rotation.Participate in education and outreach.Participate in death visits, including assistance with post-mortem cares using safe body mechanics.Precept new staff and students.MSW may audit or oversee the work of BSW.You Bring (Qualifications)Bachelor’s in Social Work (BSW), required; Master’s in Social Work (MSW), preferred.Current, unrestricted Social Work License in state of employmentOne-year paid medical social work experienceValid driver’s license, auto insurance, and access to a reliable vehicleMust be at least 18 years of ageIntermediate Microsoft Office skillsIntermediate electronic health records skills; Epic preferredAbility to maintain confidentiality about patients, families, caregivers, staff, donors, and organizationalintellectual propertyAbility to use proper body mechanics, safe patient handling, and standard precautionsBenefitsCompetitive salary with mileage reimbursementHealth, dental, and vision insurance for employees who are hired for 28+ hours per week (.7 FTE +)Retirement plans with employer matchingGenerous Paid Time Off (PTO) and holiday paid time offComprehensive onboarding, mentorship, and career developmentAbout AgraceFor more than 45 years, Agrace has been an innovator and leader in both caring for patients and their families, and in educating others about death, dying and grief. We are the largest hospice provider in Wisconsin. Well known for end-of-life care, Agrace also serves people across southern Wisconsin who are aging, seriously ill or grieving.At Agrace we are strengthened by the unique experiences, cultures and traditions of our staff, patients and clients.Together, we pursue a vision in which every Agrace staff member is treated fairly, and every patient and client experiences the respectful, individualized care they need and deserve.We foster a culture of belonging that celebrates people’s uniqueness and leads to meaningful, empathetic connections.Agrace Health Inc. is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.