Clinical Training Recommendations for Social Workers Caring for Patients with Serious Illness

These training recommendations will help social workers address the unique needs of patients living with serious illness.

Examples include health professionals working in oncology, cardiology, or primary care.

Assess the Needs and Concerns of Patients

• Know what palliative care is, and when to request a consult
• Assess patient’s physical, mental, social, and spiritual well-being at all stages of disease
• Assess caregiving needs and resources

Strengthen the Clinician-Patient Relationship and Understand Goals of Care

• Identify the patient’s surrogate decision-maker
• Have conversations with patients to understand what matters most to them now that they have a diagnosis of a serious illness, and participate in shared decision-making that is aligned with patients’ values and preferences
• Conduct advance care planning conversations and complete advance directives
• Identify how culture, race, gender, sexual orientation, and context (e.g., social determinants of health) influence patient and family decision-making in the context of a serious illness, and deliver responsive, unbiased care matched to needs and priorities
• Identify patients who are eligible for hospice, and support them to make the decision whether to enroll

Manage Pain and Symptoms

• Assess and address the suffering caused by common symptoms associated with serious illness, including pain; nausea and vomiting; constipation; dyspnea; fatigue; depression; anxiety; delirium and agitation
• Assess the feasibility and safety of the care plan with the patient (e.g., whether prescribed medications are accessible and affordable)
• Assess and identify cognitive impairment
• Identify patients that would benefit from a specialty palliative care consult for complex or intractable symptoms, and refer or discuss with the care team

Prevent Crises and Plan Ahead

• Collaborate in discharge planning
• Recognize non-physical sources of suffering, and collaborate with spiritual care colleagues to provide support when needed
  • Investigate access to virtual behavioral health support based on patient need and insurance
• Assess functioning, including mental health status, and refer patients for a home safety and/or fall risk evaluation when appropriate

Complete the Learning Pathway, Social Work Serious Illness Designation: Foundational Skills, to acquire these skills and earn CAPC Designation.

Examples include health professionals working in geriatrics, home-based care, or nursing home settings.

Assess the Needs and Concerns of Patients

• Recognize common sources of suffering for patients with serious illness, and perform a comprehensive assessment using culturally appropriate tools, including:
  • Social risk factors (presence of caregiver; caregiver burden; access to housing, food, and transportation; racism and other culturally-bound factors that influence care; financial strain)
  • Polypharmacy
  • Emotional and spiritual distress
  • Physical symptom distress (e.g., pain, dyspnea, constipation)
  • Communication barriers (e.g., vision, hearing, language, and health literacy)
  • Need for adaptive equipment

Strengthen the Clinician-Patient Relationship and Understand Goals of Care

• Conduct skilled conversations with patients and families about:
  • Bad news
  • Prognosis
  • Patient/family understanding of the illness
  • Family conflict
  • Financial strain, insurance
• Provide education regarding coping with serious illness, self-care, and spirituality

Manage Pain and Symptoms

• Anticipate the full spectrum of symptoms related to specific serious illnesses and along the disease trajectory
• Contextualize treatment and/or interventions to incorporate the values, meaning, and priorities of each individual patient to provide person-centered, family-focused, and culturally congruent care

Prevent Crises and Plan Ahead

• Identify community resources that can support patients living with serious illness, and their caregivers (e.g., housing, food, transportation, faith communities, state and local agencies)
• Identify barriers to meeting patient and family needs and honoring their priorities, and discuss the least restrictive alternatives (e.g., home redesign or board and care home versus nursing home placement) either directly, or through referral to the appropriate health professional
• Develop a crisis intervention assessment and plan, including suicide prevention

Complete the Learning Pathway, Additional Skills for Social Workers who Focus Primarily on Supporting People with Serious Illness, to acquire these skills.