SOCIAL WORKER-SPANISH SPEAKER/ LCSW/ MEDICAID ACO/ 40 HOURS/ DAY SHIFT/ BWH SOUTHERN JAMAICA PLAIN 8/20/2020
Brigham & Women's Hospital(BWH)
Jamaica Plain, MA
JOB DESCRIPTIONAPPLY The Social Worker for the Medicaid Accountable Care Organization (ACO) is a key member of the Primary Care team, providing clinical services and overseeing the coordination of care for high risk, complex patients with significant utilization of medical and/or psychiatric services and facilities.
The Social Worker for the Medicaid ACO will be expected to serve as the primary coordinator of patient care for a panel of patients, ensuring communication among providers and patient. The patients are predominantly covered by Massachusetts Medicaid and are part of the innovative Medicaid ACO strategy at Brigham and Womens Hospital.
The Social Worker for Medicaid ACO will be embedded in a BWH primary care practice and be responsible for establishing, implementing, monitoring, and evaluating high quality cost effective, patient-centered care plans.
The Social Worker for the Medicaid ACO collaborates with the interdisciplinary team in creating and improving the system of care, in determining which interventions have been most helpful, and in outlining the essential elements of these interventions so the team can develop a model that may be used by others. The Social Worker for the Medicaid ACO remains knowledgeable about performance targets.
The Social Worker for the Medicaid ACO will partner with key state and community agencies to manage patients.
The Social Worker for the Medicaid ACO will work to support the practice-based population health manager.
This position requires a broad knowledge of clinical care and systems management, case management expertise, strong clinical judgment, health care reimbursement, excellent organizational and interpersonal skills, creativity, flexibility, and the ability to multi-task.
This role is supported by 1 year of pilot funding, with potential for renewal.
PRINCIPAL DUTIES AND RESPONSIBILITIES
Provides comprehensive psychosocial assessment of patients to evaluate the mental health/psychiatric history/emotional issues/coping style, understanding of illness/adjustment/compliance, barriers to care, cultural issues, interpersonal violence. Provides mandated assessments when abuse or neglect is suspected (child, disabled adult, elder). Files reports as indicated.
Meets with patients/families in person, virtually and/or provide interventions over the phone. Utilizes evidence based practice and national standards to manage high-risk patients in the community.
Provides shortterm crisis intervention counseling for patients as needed.
Continually assesses patients behavioral health status, and provide evidence based interventions and strategies to improve patient/family functioning and /or medical adherence.
Provides recommendation and coordination of external and/or urgent psychiatric/social resources based on assessment and collaboration with patient/family.
Provides risk assessment and intervention as part of the interdisciplinary team, with emphasis on harm reduction. When necessary, refers to and coordinates with appropriate emergency services.
Provides care management around psychosocial/behavioral health needs using an evidence-based collaborative care management approach.
Acts as the lead liaison between patient and psychiatrist and other key treatment providers for patients receiving care management.
Works and collaborates with the Clinical Director for the Medicaid and the BWPO Medicaid ACO team on program intervention and design.
Provides clinical assessment with patients around chronic disease and health behavior self management obstacles.
Provides health behavior interventions to support and increase patient/family self-efficacy that include, but are not limited to, health action plans, change interventions, and motivational and problem solving techniques that address obstacles to goals.
Reviews and assists in triaging new patients with the PCP and other primary care team members, as appropriate.
Works to optimize the mental health of the high-risk medical and psychiatric patient population and to maintain these patients in the community, avoiding hospitalization when appropriate.
Improves patient and/or family understanding of and adjustment to the medical/psychiatric diagnoses to maximize benefits of medical/psychiatric intervention and enhance patient functioning throughout the course of illness. Ensures that the patient is involved in all phases of the patient care process.
Provides psycho education to patient/family regarding mental illness recovery and relapse. Works with patient/family to develop relapse prevention strategies.
Identifies resources as needed to encourage patients progress, and provides evidence based psychotherapeutic interventions to assist patient in accomplishing treatment goals.
Conducts family meetings as needed to support patient progress, collaborates with various medical providers and/or additional service providers to coordinate care.
Works effectively as part of the interdisciplinary health care team, communicating regularly with the PCP, RNCC and other members of the patients care team through the continuum of care.
Monitors the patients progress and plan of care with the aid of internal and external utilization and quality guidelines. Identifies, documents and reports issues and system barriers. Intervenes as necessary and appropriate to ensure that the plan of care and services provided are patient focused, of high quality, efficient and cost effective.
Monitors patients in non-acute facilities in collaboration with the medical team.
Acts as a resource to staff and works on a case by case basis, to coach and mentor on techniques and approaches to management of psychosocial issues in a high risk population.
Exemplifies program teachings and acts as a role model for patients by practicing behaviors consistent with goals of the program.
Presents and/or discusses clinical work in formal and informal case reviews and seminars as indicated.
May participate in research projects. May initiate/implement psychosocial programs based on patient/family identified need as indicated by the Medicaid ACO initiative. Programs may be intermittent/informal or ongoing.
Performs other duties as assigned.
QUALITY, UTILIZATION MANAGEMENT: HIGH RISK PSYCHOSOCIAL
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.
Interacts with home care, community agencies and facilities to ensure safe and timely patient care transitions
Negotiates followup contact with patient/family, community agency or facility to evaluate the effectiveness of the patient care transitions and identifies problems in service delivery
Ensures coordination of the communication process with patient/family concerning the plan of care, including coordination of family meetings and warm handoffs.
Ensures that patient/family is involved in all phases of the care process to the greatest extent possible.
Maintains current knowledge of and identifies needs in service delivery within social, governmental, protective services and legal agencies.
Participates in data collection for departmental quality assessment activities in collaboration with the care coordination department.
Partners HealthCare is an Equal Opportunity Employer & by embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law.