Social Worker - Advanced Illness Care

Essential Responsibilities Conducts comprehensive psychosocialassessments and makes appropriate referrals to community resources aswell as provides education to patients and families regarding communityresources, benefits and entitlements. Collaborates with clinical andsupport staff regarding patient/family/caregiver issues. Conductspatient and family counseling and education considering familysystem/dynamics and coping methods to all age groups and makesappropriate referrals to other community resources if indicated. Helppatient and family/caregiver develop coping strategies to managedeclining physical health, and emotional or spiritual needs. Closelypartners with patient providers and interdisciplinary care team acrossthe continuum Provides short term crisis intervention and assumesactive role of advocate for family. Assists clinicians and clinicalteams with management of transitions of care when patients are movingfrom one setting to another. Provides direct patient care support ina variety of settings. Participates as a member of interdisciplinarycare team assisting with establishing and implementation of psychosocialcare plan in patients with serious, complex and/or chronic illness whichcould include partnering with Primary Care, Hospice or AIC team members. Assists patients and family with advance care planning which includesdiscussions about goals of care/treatment, answering general questionsabout power-of-attorney documentation, the POLST form and the OregonAdvanced Healthcare Directive Form. Communicate and coordinate withother providers to ensure care is coordinated and consistent withpatient's goals of care, including AD/POLST. Assists withestablishment of POA-HC and with establishment of end-of-life care plansas needed. Provides education to patients, family members, caregiversand Housecall Providers' staff regarding mental health issues, grief,resiliency, hospice services, community resources, benefits andentitlements. Provides consultation on ethical issues that arise forHCP staff. Conducts mental status exams as requested by Providers. Provides advocacy for patients and families with various communityagencies, care facilities and other institutions as needed. Assistsclinicians with organization and/or facilitation of care conferences forassessment, education or conflict management. Experience and/orEducation Required Master's degree in social work from an accreditedcollege Current Oregon LCSW, LMSW or CSWA license Minimum 1 yearwork experience in geriatrics, home health, hospice, hospital, primarycare/specialty care clinic or other community based mental health oroutreach social work Valid driver's license, acceptable drivingrecord, and automobile liability coverage or access to an insuredvehicle CPR certification at hire or within 6 months in positionPreferred Experience dealing with substance use disorders, carecoordination and needs assessment for high- risk populations Knowledge,Skills and Abilities Required CareOregon is an equal opportunityemployer.& #8239;

Created: 2026-02-05