The oncology social worker is a core member of the oncology navigator team and provides psychosocial assessment of the needs of patients and families and formulates an intervention plan to address these needs, including but not limited to social work and counseling services. Identifies environmental, emotional, and psychosocial barriers that may affect the quality of life of cancer patients and their families and assists with access to appropriate resources. The intervention plan will enable individuals and their families to access appropriate services within the limits of available resources and achieve improved levels of health and functioning based upon optimal psychosocial adjustment. This position works collaboratively with the interdisciplinary care team across the continuum of care to develop and implement an interdisciplinary plan to provide coordinated care to improve outcomes for patients with cancer diagnoses. Serves as point of contact for providers who diagnose and treat cancer patients to offer support, psychosocial assessment, education and linkage to community resources as appropriate. The oncology social worker will also assist with care planning, case management, outreach and referrals to appropriate services.

• Ensures that social and emotional needs of patients and their families/caregivers are met in collaboration with the interdisciplinary team of healthcare professionals.
• Provides crisis intervention and supportive counseling to patients/families to support effective coping and positive outcomes.
• Assists patients in accessing resources to ensure adherence to treatment plan, including transportation, lodging and financial resources.
• Provide systemic patient and family centered psychosocial screening and assessment.
• Provide evidence-based psychosocial intervention.
• Demonstrate communication/problem solving/decision making skills.
• Provide family and caregiver support and family conferencing.
• Provide interdisciplinary teamwork and collaboration.
• Design and implement a plan of care that links patients and families with needed services and engages and supports them in managing their illness and well-being.
• Systematically follow, re-evaluate and adjust plan of care to reflect evolving needs of patients and families.
• Serves as the point-of-contact for ongoing psychosocial resources for patients, families, and for team members to provide to patients throughout the care continuum - pre-diagnosis through treatment into survivorship.
• Communicates information regarding patient status and needs to providers and identified care team members.
• Collaborates with support services (palliative care, hospice, dietician, psychologist, chaplain etc) regarding how best to meet psychosocial needs. Collaborates with internal and community resources to provide assistance to patients/families for patient needs.
• Documents meaningful, concise and timely clinical notes, social histories/assessments, and discharge planning notes.
• Participates with hospital staff on an interdisciplinary and professional basis and assists in planning, implementing and evaluating a patient's plan of care.
• Provides direct services for patients/families exhibiting psychosocial needs.
• Conducts individual and family meetings to address barriers to care and psychosocial distress.
• Consistently utilizes a holistic approach considering physical, psychosocial, spiritual, educational, safety and related criteria appropriate to the age of the patients served.
• Identifies and delivers culturally-competent social work interventions to patients/families to meet identified needs.
• Provides comprehensive psychosocial assessments.
• Collaborates with the nurse navigator in determining who will refer patients/families to the appropriate health care professionals and/or community agencies outside the hospital.
• Continually expands own knowledge and the knowledge of other staff on current resources available.
• Serves as a patient/family advocate around concerns such as patient confidentiality, informed consent, patient autonomy, and self -determination.
• Documents assessments, interventions, and referrals in the health record according to documentation standards.
• Maintains current knowledge and practice according to standards identified in the NASW Code of ethics, NASW standards for social work practice in healthcare, and State regulations.
• Leads the implementation of the Kids Konnected program for kids with a parent/caregiver that has/has had cancer.
• Ensures continuity of care with patient transfers through verbal or written report from oncology nurse navigator to social worker and vice versa.
• Demonstrates flexibility and self-direction in meeting patient and unit needs by responding as a team player.
• Provides short-term crisis intervention and individual and family counseling and support as appropriate.
• Provides group counseling as appropriate.
• Assumes the role of client advocate for the client/caregiver when needed.
• Educates and assists with Advance Directive planning including, Living Will, Power of Attorney, Surrogate and/or guardianship process, DNR and other end of life issues as appropriate.
• Demonstrates evidence of professional growth and development.