Within Hill Physicians’ care coordination framework, provide in-person or telephonic psychosocial assessments and interventions to assist patients and caregivers in making care transitions and coping with their illness, diagnosis, treatment, and/or life situation, including emotional, mental, and substance abuse disorders.
Provide psychosocial assessments of patients and caregivers that:
· Support effective planning to improve care
· Identify patient/family issues that may negatively affect the team’s treatment recommendations
· Determine how the issues may impact ability to follow the treatment plan
Offer specific interventions that improve outcomes, including but not limited to emotional, mental health, and substance abuse treatment.
Develop and implement a comprehensive psychosocial treatment plan utilizing appropriate clinical social work treatments and interventions. Interventions may include:
· Coordinating appropriate services, such as Home Health or Hospice care, appropriate other levels of care such as SNF, Board and Care, Care Givers at home.
· Education of patients, family members, and care givers around issues related to adaptation to the patient’s diagnosis, illness, treatment and or life situation.
· Participation in multi-disciplinary health care teams and representing the social work perspective with the patient, family and care providers.
· Educate care team and others regarding the role and responsibilities of the Social Worker and help staff in identifying patients needing a Social Work Intervention.
· Assist in advance care planning and completion of Advance Directives and POLST. Coordinate symptom management and/or end-of-life services.
· Assessment and referral for Medi-Cal and/or other insurance eligibility based on new entitlements and referral for SSI and or SSDI as needed or within scope of care definitions as indicated.
· Maintain a working knowledge of relevant medical/legal issues that may have an impact on the care of the patient, e.g. advance directives, and reporting for elder and/or child abuse. Provision of consultative services to other health care professionals as indicated.
· Maintain a working knowledge and liaison relationship with community agencies and resources. Determine and coordinate application of Health Plan, Medicare and Medi-Cal benefits. Maintain client privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory and accreditation standards.
· Potential travel to visit patients in Skilled Nursing Facilities and in PCP offices
Assist in managing behavioral and /or substance abuse issues. When appropriate provide training to other health care professionals on the team. Support screening, identification and management of victims of abuse, neglect, domestic violence, including elder abuse.
· Education: MSW Masters Social Work accredited by the Council of Social Work Education.
2-4 years social work experience within the last 5 years (MSW fieldwork not included), preferably in a managed care environment
· Experience with:
o A wide variety of illnesses/conditions & resulting needs
o Crisis, grief & family counseling
o A wide variety of oncological diagnosis & resulting coping & other psychosocial issues.
o Working w/ elderly & other diagnosed w/ a wide variety of dementia as well as community resources to meet needs of this population.
o Experience providing clinical services to patients w/ multiple ongoing health conditions. Works w/ nursing to insure patients are as active & healthy as possible
o Initiating/participating in end-of-life discussions w/ patients & families, assisting in hospice referrals, holding family conferences, home visits & advanced care planning
o Experience in crisis intervention, counseling & referral services to psychiatrically and/or socially high risk members
· Demonstrated ability to work on multidisciplinary team
· Must have solid psychosocial assessment skills
· Knowledge of chronic & acute disease; how it impacts patient/family functioning
· Demonstrated excellent oral/telephone & written communication skills
· Must be computer-literate &, preferably, experienced in automated clinical info systems
· Demonstrated ability to function independently as a collaborative, supportive team member
· Must be able to master detailed & complex info regarding benefits & coordination of care
- Experience with managed care delivery required.
- Optimum organizational skills with ability to meet both expected and unexpected time frames.
- Ability to coordinate effectively with a variety of customers including client, providers, office staff, health plans, internal department, community resources, and peers.
- Ability to work independently with self-initiative and discipline.
- Knowledge of ICD-10 and/or CPT coding.