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POST DATE 9/15/2016
END DATE 10/8/2016

Brigham & Women's Hospital(BWH) Boston, MA

Boston, MA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Masters Degree


General Summary/Overview Statement

As a member of the Care Coordination team, coordinates patient care through the continuum thereby facilitating the achievement of optimal quality outcomes in relation to clinical care and costeffectiveness. Provides clinical psychosocial, discharge planning and care coordination services to patients/families in all settings of care inpatient, ambulatory and community. Identifies highrisk psychosocial factors of patients/families that impact discharge planning/health status and helps hospital staff understand the influence of those factors upon the course of medical care. Assumes care coordination responsibility for patients with complex psychosocial risk (domestic violence, protective services, frail elderly, disabled, substance abuse, etc.). Assesses adaptation of families to patients' illnesses, provides crisis intervention as needed, and ensures maximum participation of patients/families in the care coordination process. Serves as an expert about and as a liaison to community resource programs. Provides consultation, teaching, research and program development within their assignment. Identifies, addresses and participates in the resolution of variances that affect the quality and/or cost of care.

Principal Duties and Responsibilities

Patient Care Management

* Identifies patient's/family's psychosocial, financial or legal concerns that affect patient care management and interacts with patient/family/interdisciplinary team to facilitate the patient care process.

* Improves patient and/or family understanding of and adjustment to the medical diagnosis to maximize benefits of medical intervention and enhance patient/family functioning throughout the course of illness. Ensures that the patient/family are involved in all phases of the patient care process.

* Provides shortterm crisis intervention counseling for patient/family as needed.

* Identifies and utilizes appropriate community resources to optimize patient outcomes. Provides liaison and referral services to community agencies.

* Provides care coordination services for patients/families during admission, ambulatory settings and ensures emergency home visiting assessments.

* Maintains confidentiality and complies with professional ethics according to professional and Departmental standards.

As a member of the Care Coordination Team:

* Advocates for the patient to ensure quality outcomes.

* Participates in the planning of care for assigned patient population in conjunction with the Care Coordination Team.

* Participates in the provision of emotional support to the patient/family during patient's illness in conjunction with the Care Coordination Team.

* Identifies and utilizes appropriate community resources to optimize patient outcomes.

* Identifies opportunities for service line process improvement.

Utilization Management

1.Intervenes with appropriate individuals/departments/agencies regarding delays in service that may have an impact on quality of patient care, length of stay or inappropriate patient admissions.

Discharge Planning

* Assesses patient's/family's adaptation to patient illness and ability to provide for patient's care needs.

* Serves as a resource to the interdisciplinary team for community based social service agencies.

* Works with the financial specialist to assist patient/family with process of addressing financial concerns, including insurance issues and Medicaid applications.

As a member of the Care Coordination Team:

* Reviews patient information for assigned caseload, determines anticipated length of stay and discharge plan and begins discharge planning process in collaboration with the care coordination team, patient, family.

* Interacts with home care, community agencies and facilities to ensure safe and timely discharge.

* Negotiates with care coordination team followup contact with patient/family, community agency or facility to evaluate the effectiveness of the discharge plans and identifies problems in service delivery.

* Ensures coordination of the communication process with patient/family concerning the discharge plan, including coordination of family meetings.

Quality Assessment/Improvement Activities

* Ensures that patient/family are involved in all phases of the care coordination process to the greatest extent possible

* Maintains current knowledge of and identifies needs in service delivery within social, governmental and legal agencies.

* Participates in data collection for departmental quality assessment activities in collaboration with the care coordination department.

* Participates in quality assessment/improvement activities designed to evaluate the appropriateness and effectiveness of the service delivery system in which care coordination operates.


As a member of the Care Coordination Team:

Ensures that the patient and family receive consistent information regarding all aspects of care in all settings of care.

Maintains effective working relationships with medical and nursing staffs, care coordination to work collaboratively to provide for the health care needs of patients.

Communicates and collaborates with team to ensure that care coordination needs of assigned patients are met without duplication of efforts and there is adequate documentation in the patients medical records on a daily basis.

Communicates and collaborates with the Care Coordination Manager/Team to ensure efficient and quality patient care and equitable caseloads.

Professional Development

As a Clinical Social Work Leader:

* Demonstrates expert social work clinical and serves as a mentor within the department and with interdisciplinary staff.

* Demonstrates active, ongoing commitment to professional growth and development of self and creates an environment conducive to the professional growth of others.

* Provides clinical consultation and supervision to social work staff and interns.

* Directs the implementation and facilitation of psycho-educational support groups and other supportive / educational forums in collaboration with the Director of Social Work and other leadership, to promote patient/family, staff, and community education regarding cancer and optimal adjustment to the consequences of cancer.

* Provides education and consultation to interdisciplinary health care providers, social work staff and community on psychosocial issues for patients.

* Demonstrates active commitment to professional growth and development of social work staff regarding psycho-educational support groups and research.

* Meets continuing education requirements to maintain licensure in Massachusetts.

* Pursues continuing education opportunities in managed care, capitation concepts and care coordination concepts and practice.


* Education: Minimum Masters of Social Work Degree in health-related discipline from an accredited program.

* 2 - 4 years experience in an acute health care setting

* Experience in working on interdisciplinary teams required.

* Licensure: Current Massachusetts Licensed Independent Clinical Social Worker (LICSW) required.

* Staff member must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served on his/her assigned unit.


Previous experience in a hospital or health care setting, bilingual (English/Spanish) preferred/Cultural sensitivity and age-specific competency required: crisis intervention, treatment skills, strong clinical assessment/judgment skills, excellent interpersonal skills including negotiation skills necessary to work within a team, excellent communication skills, strong organizational skills