Medical Social Worker

Company: Pathways Home Health, Hospice and Private Duty
Location: Sunnyvale
Posted on: April 2, 2026

Job Description:

For over 45 years Pathways has been a Bay Area pioneer, leader, and innovator in Hospice, Home Health and Palliative Care. We provide care at home or in settings such as assisted living, a nursing home, or the hospital. We have offices in Sunnyvale, South San Francisco, and Oakland. Patients and their families know us for our personalized, high-quality care, delivered with empathy, kindness, and respect. TITLE: Medical Social Worker OFFICE LOCATION: Sunnyvale PATIENT TERRITORY : Mountain View to Gilroy SCHEDULE: Full Time SHIFT: Days The posted compensation range of $39.00 - $58.98/Hour is a reasonable estimate that extends from the lowest to the highest pay Pathways Home Health & Hospice in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. Pathways Home Health & Hospice may ultimately pay more or less than the posted range as permitted by law. POSITION SUMMARY: Provide medical social services including psychosocial assessment, counseling, and community resource information and referrals as part of the interdisciplinary home health and hospice teams. AREAS OF RESPONSIBILITY: • Provides education and counseling to current and prospective hospice patients and their families regarding the Pathways Hospice philosophy, plan of care, and services. • Obtains informed consent from patients and families and assists in completing forms required for hospice admissions and discharges. • Conducts comprehensive psychosocial assessments including an evaluation of patient/family coping, social service needs, caregiving plans, and bereavement risk. • Based on this assessment, develops a comprehensive psychosocial plan of care, including individualized goals, interventions, and projected visit frequencies. Continually reviews and updates psychosocial plan of care. Integrates input from other disciplines to create a comprehensive interdisciplinary plan of care. • Provides counseling and education to help patients and families resolve issues associated with end-of-life such as anticipatory grief, caregiver stress, anxiety, memory loss and other patient mental status changes. • Identifies and enhances the strengths of the family system, including maintaining the dignity of the dying patient, assessing impact of patient/family’s unique cultural and spiritual beliefs on patient’s end-of-life needs and educating the interdisciplinary team on this impact as needed. • Provides guidance, education and referrals to help patients and families access appropriate social services including caregiving resources, advanced planning needs, mortuary arrangements, and/or financial resources. • Consistently communicates with family members of both home- and facility-based patients. Maintains timely communication with patient, family, and facility staff regarding all aspects of patient care. • Provides discharge planning for hospice patients when moving to a different care environment or when hospice is discontinued. • Knowledgeably discusses and initiates non-pharmacologic interventions as appropriate to promote comfort, improve quality of life, and manage emotional, spiritual, and physical distress. • Knowledgeably assesses and manages risk factors in the hospice setting, including behavioral health issues. Conducts screening and follow-up of patients at risk for anxiety, depression, and suicidality. Provides guidance and leadership to other members of the interdisciplinary team regarding mandatory reporting issues such as abuse and neglect. • Provides periodic weekend on-call social work services including triage and crisis intervention. • Consults, collaborates, and coordinates with the IDG and others involved in the patient’s care all patient and family services based on the patient’s and family’s preference. • Attends and actively participates in IDG meetings, presenting relevant psychosocial information concisely and professionally. Also attends and actively participates in educational in-service trainings and other agency meetings as requested by Social Services Program Director/Manager. • Collaborates with the Volunteer Resources department to train, supervise, and consult with patient care volunteers. • Collaborates with Bereavement Department to evaluate bereavement risk factors, develop individualized bereavement care plans, and provide individual and/or group bereavement counseling and education. • Participates in facility patient care conferences, in coordination with other IDG members, to discuss and clarify hospice care goals and roles of team members. Initiates care conferences as needed. • Demonstrates awareness of and adheres to the safety, infection control, and other policies of the facility. • Participates in quality improvement activities related to areas of practice as appropriate. • Demonstrates all skills of a hospice social worker, including those skills required by the agency through competency testing. • Submits weekly visit schedule of assigned patients as appropriate. Collaborates with Clinical Team Manager(s) to address scheduling needs. • Assesses, develops, organizes and delivers teaching materials for assigned home care patients as appropriate. • Helps clarify, counsel and explain the use of medical recommendations, services and options offered to Home Health patients to restore, improve and/or maintain their optimal social and health adjustment within the patient’s own capacity. • Assists patients, families and staff to understand, accept and manage the significant social, emotional, and financial factors related to a patient's health challenges. QUALIFICATIONS: • MSW degree from an accredited graduate School of Social Work. • One year of professional social work experience preferred. • Experience and demonstrated competence and comfort working with families in crisis, the frail elderly, the disabled and/or the terminally ill. • Current CPR Certificate. • California driver’s license and automobile insurance

Keywords: Pathways Home Health, Hospice and Private Duty, Cupertino , Medical Social Worker, Healthcare , Sunnyvale, California