Sara Rufasto, LMSW

• Improved patient care by conducting comprehensive psychosocial assessments and developing individualized care plans.
• Enhanced patient and family understanding of hospice services by providing thorough education and resources.
• Facilitated effective communication between patients, families, and interdisciplinary team members to ensure a seamless hospice experience.
• Supported patients in navigating complex healthcare systems, securing necessary resources, and addressing barriers to care.
• Provided crisis intervention services for patients and families experiencing acute emotional distress during the end-of-life process.
• Assisted bereaved family members with grief support services, connecting them to community resources when needed.

· Perform emotional assessments related to patients’ terminal illness.

· Collaborate with the physicians and other interdisciplinary team members to gain deeper insights into the social and mental stressors or disorders that could exacerbate symptoms related to terminal illness.

· Provide social services including short-term individual counseling, crisis intervention, treatment planning, assistance with advance directives planning, and funeral arranging.

· Advocate for patients and their families.

· Review social work notes to enhance quality improvement initiatives.

· Conduct training sessions for staff on social work duties and responsibilities.

• Improved patient care by conducting comprehensive psychosocial assessments and developing individualized care plans.

• Delivered timely follow-up calls to bereaved families, offering reassurance and valuable resources during their time of need.
• Performed clinical supervision to bereavement team and interns and coordinated orientation, education and development of team members and volunteers.
• Worked closely with funeral directors to ensure smooth coordination of memorial events honoring deceased loved ones.
• Developed a volunteer program that recruited, trained, and supervised volunteers to assist in delivering bereavement services.
• Plan and facilitate annual Hospice memorial services.

· Assess emotional factors associated with patients’ terminal illness.

· Collaborate with physicians and other members of the Interdisciplinary Team to gain deeper insight into social/mental stressors or disorders that may exacerbate symptoms related to terminal illness.

· Deliver a range of social services encompassing short-term individual counseling, crisis intervention, treatment planning, assistance with advance directives, and funeral planning.

· Champion the rights and wellbeing of patients and their families.

· Conduct assessments to pinpoint patient psychosocial needs, establish goals, and define objectives.

· Collaborate with the interdisciplinary team to address patient-identified needs and goals.

· Coordinate referrals to suitable community resources as needed.

· Advocate for the patient's interests and holistic well-being.

· Provide expert mental health support to the patient.

• Improved overall client experience by providing compassionate support during challenging times while offering practical solutions to pressing issues.
• Monitored patient progress regularly, adjusting care plans as needed to address changing needs or concerns.

· Provide critical bereavement counseling to the family, ensuring comprehensive support during their time of loss.

· Empower the patient's family with thorough education on effective coping strategies for managing grief and loss.

· Spearhead the arrangement of vital community support, facilitating referrals to essential ongoing counseling services as warranted.

· Demonstrate unwavering commitment by maintaining consistent and proactive communication through phone calls, visits, and mailings, ensuring continual emotional support whenever needed.

• Implemented creative outreach strategies aimed at raising awareness about available services among underserved populations experiencing loss or grief-related struggles.

· Collaborated closely with children and families to strategize, secure, coordinate, and oversee services from community and informal resources. These efforts aimed to enhance their social, psychological, and physical well-being, ultimately assisting them in achieving their recovery and resiliency goals.

• Provided comprehensive case management services.
• Orchestrated treatment team meetings and updated treatment plans in alignment with patient and family input.
• Applied the biopsychosocial model assessment within a medical care context.
• Developed diagnostic and treatment recommendations, presenting findings to treatment teams.
• Devised behavioral health interventions tailored to the care setting and aided in their implementation within primary care plans.
• Conducted crisis intervention counseling sessions.
• Delivered brief interventions to patients and/or their family members, either individually or in group settings.
• Crafted and monitored individualized service plans for each assigned patient.
• Served as an advocate and referral resource for patients requiring assistance from external agencies/programs.
• Maintained meticulous progress notes and recommendations in patients' medical records/Electronic Health Records (EHR).
• Consistently managed a caseload of 8-10 patients per day.