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The Role of the Social Worker in Long Term Care

The Role of the Social Worker in Long Term Care. Palliative Care Setting. Jeannine Wilson, LSW Director of Social Services, Greenwood Center. Lynne Ponto-Rodriguez Maine POLST Program Coordinator. The conversation…. Pre-admission Goals Home Home with services Palliative Care

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The Role of the Social Worker in Long Term Care

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  1. The Role of the Social Worker in Long Term Care Palliative Care Setting Jeannine Wilson, LSW Director of Social Services, Greenwood Center Lynne Ponto-Rodriguez Maine POLST Program Coordinator

  2. The conversation… • Pre-admission Goals • Home • Home with services • Palliative Care • Hospice care • Long term care • Palliative care • Hospice Care

  3. Upon Admission • Goals • Advanced Directives/ Living Will • MPOA • Guardian • DHHS Guardian • Representative • Capacity

  4. The POLST Conversation • Reviewing the Advanced Directives • Explaining the POLST terms • Accurate information • POLST Brochure • Explaining the Dying Process • Pain • Hunger • Thirst

  5. DHHS Guardian POLST Process • Conversation • Advanced Directives/ Prior code Status • Letter from Doctor • Completed POLST signed by doctor • SASE

  6. Continuity of care • Greenwood’s Process • 5 copies in front of chart(on lime green #24) • Original in doctor’s orders section • Orange stickers inside cover (DNR, DNH) • Standard Doctor’s order for MAR • See POLST for further instructions • Update Demographics' Sheet

  7. Discharge or Transfer • POLST is to accompany resident on discharged to the hospital • POLST is to accompany resident when transferred by ambulance • POLST is to accompany resident when going home • Copy sent to PCP on discharge (Mailed)

  8. The Conversation continues… • Conflicting opinions • Family wants to decide for capacitated person • Does not match Advanced Directive • Guardianship

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