The Role of the Hospice Social Worker

When we speak about hospice care, often the first thing that comes to mind is the importance of the medical care of the patient. Controlling pain and symptoms, managing medications, and addressing other immediate concerns related to their illness. A major benefit to the families who accept hospice care is the coordination of all these things so they can focus on being present with their loved one for whatever period of time they may have.

But how exactly does a patient and their family begin to process the words terminal illness, death, and the countless thoughts and emotions that come along with them?

Fortunately, hospice care uses a person and family-centered approach that includes a team of clinicians including doctors, nurses, home health aides, chaplains, counselors, trained volunteers, and social workers.

In hospice care, social workers are tasked with addressing the many emotional and psychological issues patients and families face when they travel this phase of their journey. They work to assess and evaluate the situations patients find themselves in from a problem-solving perspective. Their insights, support, and recommendations can greatly improve the experience of the patient and their family.

The social worker gets to know the patient and the background of their personal and family history, including identifying any military service. This information, as well as learning their view of the dying process, is important to collect so the social worker can help the patient and family work together in making healthcare decisions based on their goals of care.

Sometimes, a social worker will find a family under unusual stress, or with particular or unusual concerns about what they are facing as a family.  In this case, the social worker may help mediate family discussions to help get everyone on the same page.

During this time, all family members may not agree with the patient’s decisions to accept hospice care. Social workers are specially trained to resolve conflict and help with the acceptance of the patient’s wishes. For many families, these can be very emotionally charged situations and social workers assist in keeping the focus on what is important to the patient.

One of the scariest things present during this time can be fear of the unknown. The clinical team works to prepare patients and families with knowledge of what they might expect during the process. Most importantly, social workers help people to accept their emotions about the situation.

At Hospice of St. Lawrence Valley, social workers have the assistance of Resource Advocate, Brandy Walton, who works to connect families to community care agencies, respite services, Lifeline, legal services, housing, home delivered meals, prescription coverage, utility assistance and much more. Together, the social work team provides important guidance through the process of establishing managed long-term care in the home and facilitate nursing home placements if needed.

Navigating life with an advanced illness can involve countless confusing insurance matters and completing applications for nursing home placement, Medicare, and VA services can be exhausting. Hospice staff have established relationships with the many services available to our community members and work to ensure they have the fullest support available as they care for their loved one.

For many patients and families who choose hospice care, coordination of care removes a huge burden. The ripple effect of an illness and the death of a loved one moves through the entire family and it is important with this model of care that support is offered to everyone affected by the situation. Each person experiences this process differently and they are treated as individuals when difficult emotions arise.

During the COVID-19 pandemic, we would like to remind families they can seek additional information on hospice care and even refer a family member to our services. Our staff will work with a person’s physician to determine if they are eligible for hospice care or our Advanced Illness Management program. For more information call 315-265-3105.

While the presence of COVID-19 in our lives has certainly brought on many changes to our routines, not all changes are bad.

Early this summer we announced, for the first time in ten years, we would be making a change to our signature summer event. Hosting Swim a Mile for Hospice during a pandemic was not possible. Instead, we introduced My Mile for Hospice. We asked you to choose an activity and “go the extra mile” in support of our organization and those we serve. The final result of this event far exceeded anything we could have hoped for.

A total of eighty-four participants ages six to seventy and older logged nearly 2,500 miles. Hundreds of community members made donations in support of our participants’ efforts to walk, run, bike, hike, and swim (just to name a few activities) for Hospice. This change of events allowed us to welcome sixty-five new participants as Hospice supporters. While we couldn’t formally gather together, collectively this effort raised nearly $42,000, making it our most successful special event ever.

More significantly, our community rallied around the importance of hospice care in the time of a health crisis. You recognized our front-line staff and their willingness to continue to serve your friends and family during one of life’s most difficult times.

Prizes were awarded to the top three individual fundraisers, top youth fundraiser, and new this year, top fundraising team. With a total of $4,990 Shauna Gall was once again our top fundraiser, followed by long-time participant Jan DeWaters who raised $2,192, and Hospice volunteer Kay Church raising a total of $2,001. Kay also logged the most individual miles with her daily combination of stationary biking and walking for a total of one thousand three hundred miles. The top three individual fundraisers were awarded gift certificates to the Potsdam Chamber of Commerce to ensure support of our local businesses.

Ariana Baxter was the top youth fundraiser. She performed an original dance choreographed with her teammate, Emersen Garrow. A full team of new participants, the Cranberry Lake Crazies, was the top fundraising team with a combined total of $2,290. They completed the Cranberry Lake 50 Ultra – a fifty-two mile hike around Cranberry Lake in less than twenty-four hours in honor of a fellow hiker and current hospice patient.

As we all know, change is difficult. A departure from normal or what we’ve always done can be scary, but sometimes it can lead to incredible opportunities for improvement. Throughout the last few months, it has been a pleasure to interact with participants new and old and connect with community members who so generously donated to our cause. We learned why Hospice is important to you and we saw a new level of support for our organization. These are the things that have made the change to My Mile for Hospice incredibly profound.

The support from My Mile for Hospice will ensure the compassionate care our patients and their families count on will continue to be available no matter what challenges lie ahead.

From everyone at Hospice, thank you for going the extra mile!

– Kellie Hitchman, Director of Development & Community Relations

 

View all our participant’s photos online here!

Advanced Illness Management (AIM) of St. Lawrence Valley is pleased to welcome Lucille D’Agostino, FNP-C to our team to provide palliative care to individuals in St. Lawrence Co. living with chronic illness.

Ms. D’Agostino earned both her associate and bachelor’s degrees in nursing from SUNY Canton. She achieved her master’s degree and family nurse practitioner certification from SUNY Polytechnic Institute. As part of her most recent certification, she completed clinical rounds under the supervision of current AIM nurse practitioner, Marie-Paule “Missy” Heylen, ANP-C.

Although she is newly certified, Ms. D’Agostino has deep roots in caring for patients and families facing advanced illnesses.  Prior to pursuing her advanced certification, Ms. D’Agostino worked as a registered nurse for Hospice of St. Lawrence Valley, providing end of life care for more than ten years. In addition to her work with Hospice, she worked for Dr. Vijay Kumar in Gouverneur for twenty-four years.

“It’s obvious Lucille is deeply committed to providing care in this setting,” said Diane Pickering, Administrative Director for AIM. “She was passionate about her patients while providing hospice care and is returning to offer AIM patients the same commitment to their care and overall well-being.”

Advanced Illness Management serves patients in our community who are living with a chronic illness. Nurse Practitioners in the program provide home-based palliative care to AIM patients and support to those who are helping care for them.  Observing the patient in their home enables the team to consider any challenges the patient and family have with managing symptoms and other issues related to the illness. This helps to give them insights to provide practical solutions.

Once patient care is established, the AIM team collaborates with other healthcare providers and agencies to assist the patient and family in managing the illness.  In addition to helping with symptom control, the AIM team can help with the regulation of medications and extreme pain, answer questions or help to manage a sudden change with the illness.  For many AIM patients, having access to the team helps them get answers quickly, without making difficult trips to a provider’s office or the emergency department.

Life with a chronic illness can be difficult, but patients and families don’t have to manage it alone. The AIM staff strives to meet each family where they are at in their situation. Each illness is different, and the team takes a very individualized approach to each patient’s care, encouraging them to take charge of their health.  The patient establishes their goals of care and the AIM team works to help them achieve these goals to maximize their quality of life, whatever that may mean for them.

The diagnosis of a chronic illness immediately alters the lives of a patient and their family. Often the patient would benefit from the kind of services offered by Hospice; however, they are not yet eligible for this level of care according to Centers for Medicare and Medicaid Services criteria. The AIM program bridges an important gap between diagnosis of a chronic illness and hospice eligibility. AIM staff provide pain and symptom control, emotional support, and guidance with the progression of an illness throughout the disease process. As the disease advances, AIM providers can work with the patient and family to determine readiness and eligibility for hospice care. Making this transition with trusted members of the care team makes it a seamless transition and helps to ensure the highest level of support for the patient and family for as long as possible.

“The addition of Lucille to the team will help to reduce the wait for the initial provider visit with patients and families. It will also allow some flexibility in the schedule for providers to prioritize more urgent situations in the homes of patients,” said Pickering.

For a brief period during the COVID-19 pandemic, visits were provided strictly via telehealth, however, AIM providers have resumed in-person home visits with patients. Telehealth support is still available for patients who have concerns about new people in the home. AIM can provide devices to families who don’t have access and will offer training for telehealth visits. Information and extra support are just a phone call away. For more information on services provided by Advanced Illness Management call 315-262-0861.

Advanced Illness Management (AIM) of St. Lawrence Valley is pleased to welcome Lucille D’Agostino, FNP-C to our team to provide palliative care to individuals in St. Lawrence Co. living with chronic illness.

Ms. D’Agostino earned both her associate and bachelor’s degrees in nursing from SUNY Canton. She achieved her master’s degree and family nurse practitioner certification from SUNY Polytechnic Institute. As part of her most recent certification, she completed clinical rounds under the supervision of current AIM nurse practitioner, Marie-Paule “Missy” Heylen, ANP-C.

Although she is newly certified, Ms. D’Agostino has deep roots in caring for patients and families facing advanced illnesses.  Prior to pursuing her advanced certification, Ms. D’Agostino worked as a registered nurse for Hospice of St. Lawrence Valley, providing end of life care for more than ten years. In addition to her work with Hospice, she worked for Dr. Vijay Kumar in Gouverneur for twenty-four years.

“It’s obvious Lucille is deeply committed to providing care in this setting,” said Diane Pickering, Administrative Director for AIM. “She was passionate about her patients while providing hospice care and is returning to offer AIM patients the same commitment to their care and overall well-being.”

Advanced Illness Management serves patients in our community who are living with a chronic illness. Nurse Practitioners in the program provide home-based palliative care to AIM patients and support to those who are helping care for them.  Observing the patient in their home enables the team to consider any challenges the patient and family have with managing symptoms and other issues related to the illness. This helps to give them insights to provide practical solutions.

Once patient care is established, the AIM team collaborates with other healthcare providers and agencies to assist the patient and family in managing the illness.  In addition to helping with symptom control, the AIM team can help with the regulation of medications and extreme pain, answer questions or help to manage a sudden change with the illness.  For many AIM patients, having access to the team helps them get answers quickly, without making difficult trips to a provider’s office or the emergency department.

Life with a chronic illness can be difficult, but patients and families don’t have to manage it alone. The AIM staff strives to meet each family where they are at in their situation. Each illness is different, and the team takes a very individualized approach to each patient’s care, encouraging them to take charge of their health.  The patient establishes their goals of care and the AIM team works to help them achieve these goals to maximize their quality of life, whatever that may mean for them.

The diagnosis of a chronic illness immediately alters the lives of a patient and their family. Often the patient would benefit from the kind of services offered by Hospice; however, they are not yet eligible for this level of care according to Centers for Medicare and Medicaid Services criteria. The AIM program bridges an important gap between diagnosis of a chronic illness and hospice eligibility. AIM staff provide pain and symptom control, emotional support, and guidance with the progression of an illness throughout the disease process. As the disease advances, AIM providers can work with the patient and family to determine readiness and eligibility for hospice care. Making this transition with trusted members of the care team makes it a seamless transition and helps to ensure the highest level of support for the patient and family for as long as possible.

“The addition of Lucille to the team will help to reduce the wait for the initial provider visit with patients and families. It will also allow some flexibility in the schedule for providers to prioritize more urgent situations in the homes of patients,” said Pickering.

For a brief period during the COVID-19 pandemic, visits were provided strictly via telehealth, however, AIM providers have resumed in-person home visits with patients. Telehealth support is still available for patients who have concerns about new people in the home. AIM can provide devices to families who don’t have access and will offer training for telehealth visits. Information and extra support are just a phone call away.

For more information on services provided by Advanced Illness Management call 315-262-0861.