Practices professional social work with responsibility for providing, supporting or coordinating palliative care to patients with an advanced illness and their families. Supports and coordinates the comprehensive and effective delivery of palliative care services according to scope and assigned tasks, within various settings. Strong interpersonal skills needed to work with patients and families, community partners, providers and other medical office and hospital staff. Makes member/patients and their needs a primary focus of ones actions; develops and sustains productive member/patient relationships. Actively seeks information to understand member/patient circumstances, problems, expectations, and needs. Builds rapport and cooperative relationships with members/patients. Considers how actions or plans will affect members; responds quickly to meet member/patient needs and resolves problems.

• This position, knows and complies with all Kaiser Permanente quality, safety, and emergency policies and procedures. Demonstrates quality and effectiveness in work habits and clinical practice in every interaction with patients, colleagues, providers, and leadership. Ensures patient safety in the preparation and provisioning of care related to but not limited to medications, procedures, infection prevention, fall prevention, including consistent use of two patient identifiers and procedural time outs. Reports safety hazards, accidents and incidents, and unsafe working conditions promptly.


• Accountable for consistently demonstrating service behaviors and principles defined by the Kaiser Permanente Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.


• Collects subjective and objective data. Analyzes, reports, and records data. Uses data to identify psychosocial problems and create plan.


• Prioritizes patients needs. Triage patients either in person or via telephone and implements proper course of action in accordance with established protocol/guideline or in consultation with provider. Conducts telephone call backs to patients requiring follow-up care.


• Evaluates emergency situations within scope and initiates appropriate social work interventions.


• Participates in program development.


• Documents care planning and member outcomes.


• Practices within scope of practice parameters as inferred by licensure, standard social work practice, knowledge, skill level, sound clinical judgment, and KP guidelines.


• Accurately documents patient data, actions or interventions, responses, and plans for care/follow-up according to guidelines and/or standard social work practice.


• Executes delegated functions which deliver aspects of care that implement and are consistent with the care plan as prescribed by a licensed or otherwise legally authorized physician or person acting under the physicians delegated authority.


• Facilitates the coordination and integration of care between health care services.


• Specialty Position Responsibilities may vary according to program service and may include but are not limited to the following: Performs bio-psychosocial-spiritual assessment of the person in environment, in order to determine best level of care, Coaches member and the family system to prepare for shared decision making. Provides psychotherapeutic and family systems interventions as needed within the  context of advanced illness care coordination (AICC) and brief solution-focused therapy. Assists the patient/family in identifying personal goals of care and preferences for end-of-life care, and promoting communication of advance directives. Collaborates to build strong, effective relationships with referrers and their teams and with partner agency care staff to assist in development and communication of plans for co-management of patients and their transition to the next care setting. Teaches palliative care modalities to providers, referral sources and members. Assists in maintaining data for monitoring/evaluating program outcomes. Assists in identifying patients appropriate to the palliative care department. Attends interdisciplinary team rounds with partner agencies to assist with interventions for complex patients, in conjunction with the Palliative Care MD and team. Acts as liaison/interface with KP providers and resources within the system. Identifies possible problems in all care delivery systems which care for our palliative care patients. Assists with development and implementation of solutions for service providers and staff.


• In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Kaiser Permanente Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.


• Note: The union and the company are currently reviewing the qualifications and duties of this position. If it is determined that the qualifications or duties should be changed, seniority dates, dues payments, etc. will be applied on a retroactive basis based on the employment commencement date.