The Clinical Social Worker/Care Manager collaborates with the care team to create and improve the iCMP system of care, in determining which interventions have been most helpful for this population, and in outlining the essential elements of these interventions, so the team can develop a model that may be used by others. The position requires a high degree of flexibility, independence, and willingness to participate in multiple activities and to provide support to all members of the care team. The Clinical Social Worker/Care Manager must have strong communication skills and the ability to converse comfortably with patients, their caregivers, practice staff and the iCMP team. The Clinical Social Worker/Care Manager works with the care team to ensure patients are receiving the services they need to achieve an optimum quality of life.
This position may be embedded in a primary care practices and will involve carrying a caseload of patients where SW will be lead or cases may be shared with an RN Care Manager. The Clinical Social Worker/Care Manager collaborates to enhance the delivery of patient and family care services along the continuum of care. The Clinical Social Worker/Care Manager meets the patient and family’s needs efficiently and expeditiously by continuously improving the patient and family experience and helping to ensure the institutional standards of high quality patient care. Through broad knowledge of clinical care, systems management and care coordination, the Clinical Social Worker/Care Manager evaluates, develops a plan of care and facilitates the trajectory of patient care.
The Clinical Social Worker/Care Manager is involved in assessment and triage of patients and families, to ensure provision of appropriate, timely, and effective evaluation. This initial clinical evaluation may be conducted by the Clinical Social Worker/Care Manager independently, or in collaboration with other members of the care team. The Clinical Social Worker/Care Manager collaborates with the care team and communicates relevant information. Care plans are prepared in a collaborative fashion, as well. The Clinical Social Worker may provide direct intervention to patients and families and may work with the treating clinicians in psychiatry, psychology, or other disciplines, within and outside of the Partners Healthcare system, helping to ensure that treatment is focused and effective.
Principal Duties and Responsibilities:
Reviews and assists in triaging new iCMP patients with the PCP, RN Care Manager and other members of the iCMP care team, as appropriate.
Provides comprehensive assessment of patients and families to evaluate clinical needs including but not limited to mental health/psychiatric issues, behavioral and emotional issues, coping style, understanding of illness/adjustment/compliance, barriers to care, cultural issues, abuse neglect and domestic violence, educational gaps and needs, community/mental health services or gaps in care. When abuse is suspected, files mandated reports as indicated by guidelines.
Provides psychosocial assessment of families to determine: family relationships/systems as they relate to care of the patient. Identifies family decision makers and caregivers; family understanding of illness and trajectory of care. Identifies family coping style, family resources and cultural issues.
Identifies key barriers to care and patient/family’s ability to manage their health and wellness through initial and ongoing assessments.
Ensures the timely implementation of the comprehensive care plan and ensures that critical elements of the plan and trajectory of care have been communicated to the patient/family and members of the care team.
Monitors the patient’s progress and comprehensive care plan with the aid of internal and external utilization and quality guidelines, identifies, documents and reports issues and system barriers. Intervenes to ensure the plan of care and services provided are patient focused, high quality, efficient and cost effective.
Monitors patients in acute and non-acute facilities, assesses and identifies patients with complex medical or mental health discharge planning and continuing care issues and refers to other members of the care team, including nurse care manager as appropriate.
Provide caregiver/family support to promote family/caregiver cohesiveness to provide care to patient and prepare patient and families for care transitions, including end of life. Advocates on behalf of patients and families to gain access to services and resources. Refers patients to other providers, as necessary.
Coordinates and attends family/team meetings, school meetings and community meetings when appropriate.
Evaluates, coordinates, manages and documents timely and relevant information in patient electronic medical record and care management database and communicates this information to the care team in a timely fashion.
Presents in formal and informal case reviews and rounds. May initiate/implement psychosocial programs based on patient/family identified need.
Perform other duties, as assigned.
MSW/LICSW or LMHC
3-5 years experience in the field of pediatric practice, ideally with experience in private/public educational systems, trauma and/or community mental and behavioral health centering on holistic patient and family care.
Clinical experience, understanding of, and comfort working with patients of all ages who suffer complex medical and psychiatric/behavioral problems; ability to work with the families/caregivers of such patients, and ability to help patients and families/caregivers understand and access the resources required to support care.
Strong understanding of psychiatric and family system and ability to use this understanding to formulate succinct case summaries.
Good organizational and time management skills
Demonstrated ability to communicate effectively orally and in writing
Strong computer skills and use of Microsoft word/excel/outlook. Experience with electronic medical records desirable.
Strong interpersonal skills enabling effective team collaboration
Demonstrated ability to be flexible and adapt to a complex, fast-paced medical environment
Bilingual skills highly preferred
Position is a substantially mobile position with travel to practices , patient’s home, community and school meetings as deemed necessary for patient/family care.
Individual must have own transportation. EEO Statement Equal Opportunity Employer