WHAT DOES A HOSPICE SOCIAL WORKER DO?
Published: Jul 22, 2025 - The Hospice Social Worker assesses each client's psychosocial condition, including emotional and social factors that affect illness, treatment response, and care needs. This role provides direct counseling, supports goal setting, develops interventions, and advises clients, families, and agency staff on appropriate community resources and eligibility. The worker also participates in care planning, communicates client condition changes to the physician and care team, and maintains accurate and timely documentation.
A Review of Professional Skills and Functions for Hospice Social Worker
1. Hospice Social Worker Duties
- Care Coordination: Coordinate care to enhance the patient’s quality of life and counsel them and their caregivers as they journey through the end-of-life stages.
- Goal Setting: Establish, implement, and evaluate goals and objectives for social services, along with handling some of the day-to-day details of the patient’s medical care.
- Team Collaboration: Collaborate with a team of providers that may include a hospice RN, LPN, aide, chaplain, music therapist, massage therapist, and volunteers to provide world-class care for the patient.
- Patient Assessment: Make the patient’s initial evaluation within 5 days of hospice admission and re-evaluate the patient's social work needs during each subsequent visit.
- End-of-Life Planning: Assist patients and caregivers in planning for funeral arrangements, and financial, legal, and health care decisions.
- Advance Directives: Educate patients and caregivers on, and assist in, the preparation of advance directives.
- Resource Referral: Provide information to patients and caregivers regarding community agencies and referral services.
- Social Evaluation: Carry out social evaluations, including family dynamics, caregiver abilities, communication patterns, high risks for suicide, neglect or abuse, and plan interventions based on evaluation findings.
- Psychosocial Assessment: Assess the psychosocial status of patients and caregivers related to the patient’s terminal illness.
- Coping Counseling: Counsel patients and caregivers about stress and other identified coping difficulties.
- Cultural Assessment: Assess for and educate staff on any special needs related to the culture of patients and their caregivers.
- Cultural Communication: Educate on communication, the role of family, space, and any special traditions.
- Bereavement Support: Provide bereavement support to patients, caregivers, and hospice personnel.
2. Hospice Social Worker Responsibilities
- Social Work Services: Responsible for rendering professional social work services to patients in their home through assessment, development, implementation, and evaluation of the social and emotional needs of patients by organization policies and procedures applicable to social work standards and governmental laws and requirements within the scope of medical home care.
- Practice Standards: Maintain standards of social work practice by NJ Department of Health requirements, NJ Social Work Code of Ethics, The Joint Commission, and organization policies and procedures.
- Clinical Judgment: Ensuring professional standards of care and practice that provide for safe and effective patient outcomes is reflected in clinical judgments and critical thinking.
- Team Documentation: Assure clinical judgment reflects professional standards through documentation and case conferencing with the team.
- Psychosocial Assessment: Perform initial psychosocial and bereavement assessment of patients that assists the interdisciplinary team plan of care and treatment goals.
- Care Plan Management: Ensure the plan is received and updated.
- Risk Documentation: Assure that risk factors and treatment goals are documented.
- Patient Counseling: Instruct and counsel patients and families in treating and coping with social and emotional responses related to recovery and/or terminal needs.
3. Hospice Social Worker Functions
- Patient Counseling: Provide counseling to patients utilizing appropriate methodologies based on the social and emotional needs of the patient.
- Intervention Documentation: Interventions are documented and are consistent with the social and emotional needs of the patient and family.
- Assessment Documentation: Ensure documentation of assessments, interventions, and planning meets the organization's timelines.
- Care Communication: Ensure pertinent patient information and plan of care are communicated promptly to the primary nurse and appropriate team members.
- Case Conferencing: Conduct case conferences throughout care and document accordingly.
- Patient Authorization: Recognize the need for authorization of a patient when there is a change in status.
- Care Collaboration: Collaborate with the RN Case Manager for follow-up.
- Discharge Planning: Assist with the preparation of a safe and organized patient discharge plan.
4. Hospice Social Worker Job Description
- Problem Reporting: Report patient care problems, along with possible solutions, to the primary care nurse or appropriate social work management personnel.
- Supervisor Communication: Communicate with the supervisor about problems in practice or any particular care needs.
- Recommendation Counseling: Assist patient and family with the understanding and acceptance of medical recommendations and advise them on how to follow the recommendations.
- Adjustment Support: Provide services to assist with the adjustment to terminal illness.
- Teaching Documentation: Document teaching regarding treatment plan recommendations.
- Resource Identification: Identify community resources to assist patients and families with end-of-life or discharge care planning.
- Follow-up Support: Provide follow-up to the patient and family to ensure implementation.
- Needs Assessment: Assess and document patient and family social, emotional, financial, and psychological needs as well as resources on the Comprehensive Assessment.
5. Hospice Social Worker Overview
- Needs Assessment: Assess the social, spiritual, and emotional needs of the patient and family to estimate the patient’s and family’s ability to cope with the problems of daily living and a terminal illness.
- Competency Supervision: Supervise, assess, and complete Initial and Annual Competency.
- Team Support: Assist the physician and other Hospice team members to understand the spiritual, emotional, and social factors related to the patient’s health problems so that each patient’s plan of care fosters spiritual well-being and human dignity.
- Service Coordination: Ensure that social service and counseling activities are integrated and coordinated within Hospice.
- Care Planning: Develop specific, measurable, realistic plans and objectives that enhance social service delivery.
- Psychosocial Assessment: Perform a psychosocial assessment and reassessment on all terminally ill patients, including pediatric, adolescent, geriatric, and the general patient population.
- Emotional Support: Answer questions and offer emotional support to the patient and family.
- Care Implementation: Implement the Plan of Care provisions to meet patient and family needs, which include social service goals for alleviating problems, supportive counseling, problem solving, community referrals, pre-bereavement, and bereavement care.
- Needs Re-evaluation: Regularly re-evaluate the patient’s and family’s psychosocial needs.
6. Hospice Social Worker Details and Accountabilities
- Psychosocial Assessment: Assess the psychosocial status of the client and social and emotional factors related to the client’s illness, need for care, and response to treatment.
- Casework Services: Provide direct social casework services to clients and families, including assisting with goal setting, counseling, planning, and providing interventions.
- Resource Advising: Advise agency personnel, clients, and families of appropriate community resources, their eligibility criteria, and regulations.
- Care Plan Development: Participate in the development and periodic renewal of the client’s plan of care.
- Treatment Reporting: Observe and report to the physician the response of the client to treatment and changes in his condition.
- Care Communication: Maintain verbal and/or written communication with other personnel involved with the care of the client.
- Record Maintenance: Maintain appropriate and timely client care records, including observations, treatments, client response to treatment, and changes in the client’s condition.
- Meeting Participation: Attend and participate in appropriate client care conferences, staff meetings, and agency committee meetings.
7. Hospice Social Worker Roles
- Psychosocial Assessment: Visit hospice patients and families to complete psychosocial assessment, provide education, and support.
- Problem Resolution: Assist patients and families in resolving personal and environmental difficulties by providing information, referral, coordination, and advocacy to enhance their ability to cope with factors related to their illness.
- Care Plan Counseling: Counsel and assist patients and their families to participate in the development of the hospice plan of care.
- Caregiver Support: Serve as a supportive caregiver to the Hospice Interdisciplinary Team.
- Care Plan Management: Responsible for the development, implementation, and timely revision of the care plan in coordination with the family and hospice team.
- Team Participation: Participate in interdisciplinary team meetings, providing psychosocial assessment information relevant to the plan of care.
- Factor Assessment: Assess, document, and report to the hospice interdisciplinary team the social and emotional factors concerning the patient's capacity and potential to cope with problems of daily living.
- Record Accuracy: Accurately complete all documents about patient care and services provided within 24 hours in neat, timely, accurate, concise, and legible records and reports.
8. Hospice Social Worker Additional Details
- Social-Emotional Assessment: Assess significant social and emotional factors for patients and families.
- Care Plan Support: Help the patient and family to understand, accept, and follow the care plan.
- Patient Advocacy: Use all available means to help patients and their families live better within illness limitations.
- Program Participation: Participate in ongoing educational programs and special projects.
- Staff Support: Support staff with loss and patient and family issues.
- Social Service Delivery: Qualified professional who provides skilled social services to patients and their families on an intermittent basis in the patient’s home or facility.
- Team Coordination: Performed by the physician’s orders, plan of care, and coordinated with other team members.
- Psychosocial Counseling: Provide initial psychosocial evaluations, ongoing psychosocial counseling, and direct casework services.
9. Hospice Social Worker General Responsibilities
- Comprehensive Assessment: Perform comprehensive patient assessments.
- Scheduled Visits: Provide patient visits as scheduled.
- Crisis Intervention: Provide short-term crisis intervention and individual or family counseling.
- Electronic Documentation: Utilize the electronic medical record system, Brightree, to complete documentation.
- Advocacy Support: Serve as a patient and family unit advocate.
- Clinical Social Work: Provide clinical social work to the hospice population.
- Social Evaluation: Carry out initial and ongoing social evaluations, including family dynamics, caregiver abilities, communication patterns, neglect or abuse, and plan intervention based on evaluation findings.
- Service Coordination: Participate in the coordination of services with other hospice team members and community resources.
- Documentation Compliance: Maintain and process all documentation in compliance with agency standards.
10. Hospice Social Worker Responsibilities and Key Tasks
- Scheduled Visits: Provide patient visits as scheduled and complete patient care within the designated timeframes.
- Accurate Documentation: Complete all documentation accurately and completely.
- Social Work Interventions: Provide, modify, or discontinue medical social work modalities and interventions based on ongoing assessment or reassessment of the patient’s clinical status and the plan of care.
- Psychosocial Evaluation: Complete psychosocial evaluations of patients.
- Team Collaboration: Collaborate with all members of the interdisciplinary team to ensure the patients’ psychosocial needs are addressed on an ongoing basis.
- Goal Setting: Assist with goal setting based on care discussions with the patient and family.
- Care Plan Execution: Assist in the execution of the care plan.
- Needs Assessment: Assess hospice patients and family to identify psychosocial, financial, environmental, and community needs.
- Psychosocial Education: Provide psychosocial education to hospice patients and their families about coping skills and hospice.
- Care Planning: Participate in the patient care planning process and collaborate with the Interdisciplinary Team to promote coordination of patient care.
- Resource Coordination: Coordinate local agencies and community resources that may be of help to hospice patients and families.