CLINICAL SOCIAL WORKER LEAD / 40 HOURS / BWH PRIMARY CARE
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POST DATE 9/17/2016
END DATE 11/5/2016
Brigham & Women's Hospital(BWH)
JOB DESCRIPTIONCLINICAL SOCIAL WORKER / PRIMARY CARE AND ICMP COMMUNITY HEALTH WORKER LEAD
The clinical social worker is a key member of the Primary Care team who provides and oversees the provision of psychosocial care for selected patients and families. Conducts bio-psychosocial assessments, provides intervention and treatment as indicated. Identifies highrisk psychosocial factors of patients/families that impact health status and helps hospital staff understand the influence of those factors upon the course of medical care. Assumes clinical evaluation, intervention and planning for patients with complex psychosocial risk (homelessness, protective services, frail elderly, disabled, psychiatric and substance abuse, etc.). Works effectively as part of interdisciplinary health care teams. Provides clinical services to patients/families that address psychosocial, environmental, age specific and cultural issues in order to maximize emotional, social and physical well being and the effective use of health care and community resources. Collaborates with and provides social work consultation to other disciplines within the setting and community. Participates on Departmental, Hospital, Satellite, community task forces and committees.
PRINCIPAL DUTIES AND RESPONSIBILITIES: Indicate key areas of responsibility, major job duties, special projects and key objectives for this position. These items should be evaluated throughout the year and included in the written annual evaluation.
Provides assessment of patients to evaluate mental health/psychiatric history/emotional issues/coping style, understanding of illness/adjustment/compliance, barriers to care, cultural issues, abuse/neglect and domestic violence.
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.
Employs a range of clinical interventions such as individual, group or family counseling. Provides caregiver/family counseling/support to promote family cohesiveness to provide care to patient and prepare families for end of life. Advocates on behalf of patients and families to gain access to services and resources. Refers patients to other providers, as necessary.
Develops comprehensive bio-psychosocial assessments responsive to age appropriate and cultural needs and concerns. Employs a range of clinical interventions such as psychotherapy (individual, couples, families, and group), psychosocial counseling, crisis intervention, care coordination, complementary therapies, information and referral and safety planning. Advocates on behalf of patients and families to gain access to services and resources.
Provides mandated assessments when abuse is suspected (child, disabled adult, elder) and safety assessment when domestic violence is reported. Files reports as indicated.
Identifies patients psychosocial, financial, legal, psychiatric or substance use that effect patient care management and collaborates with the team to facilitate patient care process.
Works effectively as part of the interdisciplinary health care team, communicating regularly with the team and other members on cases and as issues arise. Documents timely and relevant information.
Coordinates family/team meetings, as needed and when appropriate. Provides psychosocial consultation on patient care planning and patient/family management and community resources. Implements psychosocial programs based on patient/family identified needs.
Facilitates the appropriate and efficient use of hospital and community resources.
Participates in formal and informal clinical case reviews, clinical supervision, educational seminars and research projects.
TEACHING AND EDUCATION:
Assesses patient/family learning needs, styles and readiness. Educates patients/families based on treatment plan, identifies barriers to care, diversity issues and learning styles.
Mentors and may supervise students and staff. May teach in Departmental and Hospital seminars, workshops and rounds.
Collaborates and consults with patient, families and providers within the Practice Setting and community to develop and implement patient care plans. Refers to and collaborates with Departmental programs, outside agencies, facilities, payors, and other relevant community resources.
Takes responsibility for own administrative duties, including timely and appropriate documentation in patient medical records, timely and accurate daily reporting of activities and Hospitals scheduling systems, and accurate reporting of time worked.
Attends and participates in Staff Meetings and interdisciplinary meetings/rounds.
Participates in Departmental and Hospital committees.
Adheres to the professions clinical standards and NASW Code of Ethics.
Adheres to the Department and Hospital standards, policies and procedures.
Adheres to Departmental and Hospital quality/safety standards.
Is responsible for own professional development. Attends pertinent continuing education and professional activities related to job responsibilities and career goals. Keeps current with social work and health care developments pertinent to job and profession. . Complies with licensure requirements.
Performs other duties as indicated.
PRINCIPAL DUTIES AND RESPONSIBILITIES (GRANT FUNDED FOR 1 YEAR)
CLINICAL ROLE (0.5 FTE)
REFER TO CLINICAL PRACTICE SECTION ABOVE
CHW SUPERVISOR ROLE (0.5 FTE) (0.5 CHW SUPERVISOR ROLE IS PILOT FUNDED GUARANTEED FOR A YEAR)
Provide 1:1 supportive/reflective supervision for a team of 5 CHWs,
Oversee hiring process of new CHWs as needed,
Oversee intake process for all new patients and determine appropriateness for CHW services in conjunction with the medical case management program,
Develop and/or adapt intake and follow up tools and train CHWs to implement,
Support CHWs to conduct basic needs assessments and make appropriate referrals to preventive and primary health care services,
Provide regular direct observation and feedback of CHW performance during home visits or in the clinic,
Maintain relationships and consistent communication with behavioral health teams at the primary care clinics and inpatient setting,
Assess training needs of staff and formulate appropriate training plan,
Facilitate case conferencing with CHW team to discuss client cases and provide mutual support,
Be available on an on-call basis during business hours to consult with CHWs and provide intervention support and action plan,
Work with BWH iCMP CHW program Medical Director and contribute to strategic planning for the program,
Interact in a professional, respectful manner with all patients, families and staff,
Participate in the review and revision of program policies,
Participate in program design and training as needed,
Participate in team meetings,
Assure quality service delivery by CHWs and oversee data collection and reporting with responsibilities including but not limited to the design and maintenance of program database in conjunction with project manager and iCMP data