The statements below describe the general nature and level of work being performed in this role. They are not intended to be a complete list of all duties, and additional responsibilities may be delegated as required.
1. Orientation of the new patient and family to dialysis:
a. Meets with the prospective patient and his/her family to assist with an initial understanding of renal disease and dialysis as treatment, and offers emotional support to them as needed.
b. Completes an initial psychosocial component to the Interdisciplinary Assessment within 30 days of admission, a subsequent assessment at 90 days, then an annual update which is filed in the patient's medical record.
c. The concept of Advanced Directives is reviewed with the patient and family. Any concerns regarding the patient's emotional state are discussed with the attending physician and Administrative Nursing Director.
d. Any immediate needs, such as transportation to/from the clinic, are addressed as soon as possible upon/ after admission to the facility.
e. The Care Plan is completed within the first 30 days of admission. Subsequent Care Plans need to be implemented within 15 days of completing the Interdisciplinary Assessment. Options for treatment of ESRD are reviewed with the patient, and the social worker acts as liaison with the physician to provide all necessary information regarding modalities to the patient.
f. The CMS 2728 form is completed per Network and unit specifications; a screening of eligibility for Medicare and/ or Medi-Cal is performed when appropriate.
2. On-going psychosocial support of ESRD patients including, but not limited to:
a. Helping the patient to achieve an optimum level of function, utilizing available resources in the facility, family, and community.
b. Addressing recurrent issues such as: insurance eligibility/coverage, transportation provisions, vocational rehab, and ESRD acceptance.
c. Assisting the patient in changing the treatment modality (e.g. transplant), or permanent transfers to other units.
d. Being available to patients with special psychosocial needs and available to patients upon patient request.
3. Record Keeping
a. Responsible for making entries in the patient's medical record in accordance with the requirements as established in the Medicare Conditions of Coverage as a minimum.
b. Care Plans are reviewed annually for stable patients and monthly for unstable patients.
c. Conducts Patient Satisfaction surveys at least annually and Quality of Life surveys as appropriate and reports findings to the Quality Improvement Committee.
4. Communication With Others
a. Attends patient care conferences and staff meetings on a regular basis.
b. By prior arrangement with the Administrative Nursing Director, presents in-service lectures of interest to the staff.
c. Serves as an active member of the facility Continuous Quality Improvement committee.
d. Establishes contact with outside agencies as appropriate and is knowledgeable concerning the services of:
i. The National Kidney Foundation
ii. American Association of Kidney Patients
iii. American Kidney Fund iv. Other related ESRD groups
5. Other duties as assigned.