Pioneer Medical Center

Hospice Social Worker

The  Hospice Social Worker is a hybrid role and will be part of the Hospice Interdisciplinary Team (IDT) providing supportive services to patients and families to help them deal with the emotional, social, and financial impact of illness and anticipated death, and to assist the Rural Health Clinic with Patient Care Management Planning as part of the Clinic's endeavor to promote population health in the community.

This position will also be responsible for being a Bereavement Coordinator.  A Bereavement Coordinator is responsible for the planning and implementation of the bereavement aspect of the hospice’s services.


  1. Supports and practices the mission and philosophy of Hearts and Hands Hospice and the Pioneer Medical Center.
  2. Performs those management tasks and administrative functions outlined herein or as directed by the Hospice Manager.
  3. Provide social work services to Hospice patients/families including but not limited to:  personal counseling, group and family counseling, crisis intervention, benefit determination and assistance, assistance with social, economic, and survival needs, advocacy, information and referral, and case management.
  4. Establishes service and provider linkages with allied health and social service agencies and institutions of behalf of hospice patient/families, with appropriate follow-up and advocacy.
  5. Maintains written records per hospice policies.
  6. Maintains a high level of professional competence, with ongoing development of social work practice and interdisciplinary issues related to death, dying and bereavement.
  7. Performs other functions, attends meetings and conferences, and shares in the support, development and community education of the Hospice concept and philosophy, as requested.
  8. Makes oral/written report to the Hospice Manager in a timely fashion and as requested.
  9. Maintains and fosters confidentiality of all information.
  10. Assists in the development of the annual budget as related to the social services aspect of the program.
  11. Provides a minimum of one in-service annually for staff and volunteers.
  12. Participates in volunteer training, educational programs, and fundraising  activities.
  13. Adheres to the organization’s Standard of Conduct and all other policies and procedures.

 Serve on the Hospice Interdisciplinary Group.  Function as a team member by


  1. Develops and coordinates bereavement plan of care based on psychosocial and bereavement assessments.
  2. Advises staff of funeral times and locations.  Attends wake and or funeral when possible.
  3. Assures that hospice staff who work with families in bereavement are adequately trained.
  4. Provides family with grief literature, notes, bereavement letters, following death and during bereavement period for a period of 13 months post-death (longer if assessment warrants)
  5. Remains in contact with the family following patient’s death to determine needs, provide support, and make necessary referrals to IDT and community resources.
  6. Serves as coordinator of the Bereavement Team and all Community Grief Groups.
  7. Works with Hospice Manager and Nursing Director to develop, implement and evaluate grief support groups within the Pioneer Medical Center and the community.


  1. Identifies and patient needs at the individual and population levels to effectively plan, manage and coordinate patient care in partnership with patients/families/caregivers.  Emphasis is placed on supporting patients at highest risk.
  2. Systematically identifies patients who many benefit from care management through defined protocols
  3. Determines the subset of patients for care management, based on the patient population and practice's capacity to provide services
  4. Applies a comprehensive risk-stratification process for the entire patient panel in order to identify and direct resources appropriately
  5. Establishes a person-centered care plans for patients identified for care management
  6. Provides written care plans to the patient/family/caregivers for patients identified for care management
  7. Documents patient preference and functional/lifestyle goals in individual care plans
  8. Identifies and discusses potential barriers to meeting goals in individual care plans
  9. Includes a self-management plan in individual care plans
  10. Integrates care plans across settings of care for accessibility to outside organizations


  1. Must be familiar with the Hospice concept, philosophy, and its implementation and have the ability to identify and assist in coordinating the needs of the terminally ill and their families
  2. Ability to understand and promote effective interaction between the members of the IDT, other hospice members, nursing home, hospital, and community members.
  3. Willingness and ability to travel within the Hospice service area.
  4. Awareness of community resources, which may be needed by patients and families.
  5. Personal qualities enabling him/her to work effectively with patients, families, and staff.
  6. Physical and emotional health necessary for the accomplishment of the job.
  7. A desire for continued personal and professional growth and development
  8.  Effective verbal, nonverbal, and written communication skills.


  1. Current Montana Drivers License and the ability to be insured
  2. Bachelors Degree in Social Work, Psychology, Sociology, or similar field




Patient care visits in home, nursing home &hospital settings, occasional travel within community and surrounding cities for the purpose of networking and outreach education. Category II:  Task that may involve occasional exposure to blood, body fluids or tissue, but are not part of the routine job description.         

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