Responsible for providing assessment and support related to social determinants of health for patients across the lifespan in Primary Care. Acting as an embedded team member, this person is accountable to improve patient health outcomes by serving as the liaison between ambulatory care, inpatient and community services.
· Masters Degree
· MSW required; LICSW preferred
· Minimum two years of ambulatory care experience preferred
· Motivational interviewing experience preferred.
· Experience with advance care planning
1. Assessment and resource facilitation to address social determinants of health such as but not limited to: complex psychosocial / legal / financial concerns.
2. Works as an embedded member of the Care Coordination team on cases involving social barriers and serves as the patient advocate within the ambulatory clinical team and community at large.
3. Develops and maintains relationships with and working knowledge of private, state and federal community based agencies and services including eligibility and access requirements.
4. Provides patient education regarding specific health care skills and general disease concepts, counsel's patients/families about adjustment to illness and medical recommendations inclusive of goals of care, treatment decisions, and Advance Care Planning.
5. Performs needs assessments, prioritizes patients' needs / choices, and collaborates with the interdisciplinary team, patient/family, and community resources using best practice approaches in order to fully develop/organize treatment plans with optimal outcomes.
6. Ability to triage patient needs in real time and ensure comprehensive and timely hand off of patient care plans and assessments.
7. Prepares and maintains required documentation within the EMR for continuity of care. Complies with state and federal mandates for documentation and reporting.
8. Duties include patient outreach, facilitating care navigation for patients and their families, assisting with collaborative care plan implementation, overcoming barriers to care, working in concert with primary care team.
9. Provides ongoing educational needs to staff and care team members concerning social work services and community resources.
10. Active participation in complex care reviews, assigned committees, quality improvement activities, care coordination team meetings and Core Physician initiatives and other duties as assigned.