JOB SUMMARY:

• In collaboration with a multidisciplinary team, the social worker may complete intake assessments, assist with treatment planning, monitor patient progress, facilitate patient and family meetings, and support discharge services. The social worker may also provide psychotherapy utilizing brief therapy models incorporating crisis stabilization and cognitive behavioral techniques. Participates in health quality improvement and evaluation processes.
• This position supports discharge and aftercare services that support patient self-management, adherence to treatment plans, and reduction of unnecessary utilization. Through an integrated approach, may conduct office visits, and telephonic follow-up for patients and their families to navigate and access community-based services and resources.
• May also provide psychotherapy utilizing brief therapy models incorporating crisis stabilization and cognitive behavioral techniques.

REPORTING RELATIONSHIPS:

• Supervised by: Clinical Manager, Population Health
• Supervision provided to: None.

JOB TASK:

• Interview patients/families within the caseload to assess functional level according to professional standards. Conduct family meetings to address goals of care and long-term care planning. Identify physical, social, psychological, and financial needs and complete psychosocial assessment during phone calls, office visits, and home visits.
• Develop treatment plan in conjunction with other team members that assists client in achieving highest possible level of functioning and self-management.
• Conduct individual and group education sessions to assist patient/family in addressing emotional, financial or social issues and barriers to continuing control of healthcare conditions.
• Complete appropriate care referrals to community resources and providers as needed. Demonstrate flexibility and creativity in identifying community resources. Transfer accountability to the appropriate person or agency upon patient discharge to provide smooth transition from outpatient services.
• Actively participate in daily rounds in order to develop Interdisciplinary Treatment Plan (ITP) and assure timely and efficient planning for all patients.
• Arrange and facilitate peer consultation/health team meeting/family conference when necessary to advance coordination of complex services/resources and financial issues.
• Serve as liaison between the assigned client areas and other departments to provide continuity of care across the delivery system.
• Maintain current resource manual of relevant information for all community resources. Evaluate resources through onsite visits if needed to assure quality and accuracy of information provided to patient/family.
• Establish a means of communicating and collaborating with physicians, team members, payers, and administrators to provide effective, appropriate, and efficient services.
• Maintain accurate timely documentation of actions/services.
• Explore strategies to reduce resource consumption for target populations; implement and evaluate outcomes.
• Maintain professional development best practices and continuing education requirements for licensure.
• Assist with special projects and other duties as assigned.