Description
Provide psychosocial support to patients and families coping with chronic, acute, or terminal illness. Deliver counseling, care coordination, and referrals; advise family caregivers; and address barriers to care. May provide case management, discharge planning, and interventions that promote health, prevent disease, and improve access to healthcare.
- • Collaborate with physicians, nurses, and allied staff to assess psychosocial needs and inform care plans.
- • Conduct biopsychosocial assessments and review records to identify barriers to treatment and recovery.
- • Provide individual and family counseling to help patients cope with illness, treatment, and life adjustments.
- • Facilitate support groups and educate family members on caregiving and coping strategies.
- • Coordinate discharge planning and transitions of care to home or other facilities.
- • Refer patients and families to community resources for financial assistance, housing, transportation, legal aid, or education.
- • Advocate for patients during crises and navigate healthcare systems on their behalf.
- • Develop and implement care plans using consultation data and social work expertise; follow through to ensure service efficacy.
- • Modify interventions and care plans in response to changes in patient status or goals.
- • Monitor, evaluate, and document patient progress toward measurable goals in the treatment plan.
- • Screen for and report suspected abuse, neglect, or exploitation and coordinate with protective services.
- • Educate patients about advance care planning, end-of-life options, and symptom management.
- • Provide health promotion and disease-prevention interventions to improve adherence and outcomes.
- • Assist with Medicaid and Medicare applications, authorizations, and required documentation.
- • Supervise or mentor social work interns or support staff as assigned.
- • Participate in quality improvement, program development, or community outreach to enhance patient services.
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Healthcare & Human Services
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O*NET occupational data (work activities, skills, knowledge).
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Last reviewed: Jan 2026
