Behavioral Health Care Manager (Social Worker)

Oregon Health & Science University•Portland, OR

About The Position

The behavioral health care manager (BHCM) position is a behavioral health provider who operates in the Collaborative Care Model (CoCM) as part of our integrated behavioral health teams. The behavioral health care manager is a core member of the CoCM team, including the patient’s medical provider (primary care provider, or referring specialty provider) and psychiatric consultant, traditional health care worker (THW) if available, as well as the larger clinic team to ensure continuity of care. The BHCM is responsible for supporting and coordinating the mental and physical health care of CoCM patients on an assigned patient caseload with the patient’s primary care provider and the CoCM psychiatric consultant. When appropriate, the BHCM may also coordinate care with other internal and external mental health providers. This position involves a high degree of clinical complexity and advanced level of skill in delivering evidence-based interventions targeted to improve wellbeing and health for a large variety of patients with emotional and behavioral concerns commonly seen in a primary care setting. The work includes screening and assessing patients for common mental health and substance use disorders, providing education about these conditions, discussing available treatment options, and facilitating patient engagement and follow-up care. The BHCM also is responsible for systematically tracking treatment, engagement, and response (via a registry) and for monitoring patients (either in person, by phone or virtual visit) for changes in clinical status and treatment side effects or complications. The BHCM supports the patient in their management of their psychotropic medication, focusing on treatment adherence monitoring, side effects and effectiveness of treatment. Additionally, the BHCM provides brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving therapy, motivational interviewing, and other treatments as appropriate. The role also involves participation in regular (weekly) caseload consultation with the psychiatric consultant and communication of resulting treatment recommendations to the patient’s continuity medical provider. The BHCM performs duties with minimal supervision. Work is reviewed for adherence to procedures, regulations, standards and for overall effectiveness. The BHCM position is expected to serve as an advocate for collaborative behavioral health within the physical health care setting. OHSU Family Medicine at East Portland is a new Federally Qualified Health Center (FQHC) located on the Adventist Hospital campus. East Portland joins our existing health center, Richmond Clinic, in providing excellent care to Portland’s most vulnerable communities. Some applicants may qualify to apply for student loan repayment due to FQHC designation. We are committed to providing an open and equitable recruitment process with the goal of recognizing diverse lived experience that will contribute to the success of the organization and goals of this position. We are deeply committed to a community of excellence, equity, and diversity and welcome applications from candidates who will contribute to the diversification and enrichment of ideas and perspectives. Diversity, Equity and Inclusion are core values and accountability to these values helps us better serve our diverse community.

Requirements

Master of Social Work (MSW)
Certificate of Clinical Social Work Associate (CSWA) or Licensed Clinical Social Worker (LCSW) required for employees who practice clinical social work.
Experience in behavioral health counseling and brief short-term therapy strategies, and case management is required.
Demonstrated commitment to valuing diversity, equity and inclusion in the clinic and learning environment.
Ability to contribute to the success of the organization through support of and seeking out diversified ideas and perspectives.
Ability to utilize assessment information and collateral information to conceptualize patient psychopathology.
Skill and expertise in conducting group and individual psycho-educational classes and brief, short-term therapy strategies that will help strengthen the patient's overall physical and mental health.
Incorporation of self-management, home-based practice in care planning.
Skill in efficiently organizing time so that unscheduled, same day services are routinely available to care team members.
The ability to exercise sound judgment in appraising situations and making decisions regarding complex physical and behavioral health treatment issues in consultation with the primary care teams.
Skill in developing effective working relationships with peers, supervisors, and professionals in related disciplines.
Ability to manage complex personal interactions.
Demonstrated ability to act with minimal supervision on personal initiative using sound clinical judgment.
Strong written and verbal communication skills.
Ability to maintain confidentiality regarding patient care information and chart contents as use of patient record and privacy of individuals must be protected to the fullest.
Ability to maintain documentation in compliance with State, Federal, Professional and Ethical guidelines.
English Ability to perform the job duties with or without accommodation.

Nice To Haves

Training in Integrated Behavioral Health
Health care experience
Experience and/or interest in Collaborative Care.
Experience in a Primary Care Ambulatory Clinic setting.
Experience with program development and evaluation.
3 years’ experience in similar position
Knowledge of the principles and practices of behavioral health consultation, including assessment, diagnosis, treatment planning, cognitive-behavioral counseling strategies and their application to population-based care for preventive and chronic care issues.
Working knowledge of evidence-based psychosocial treatments and brief behavioral interventions for common mental health disorders, when appropriate (e.g., motivational interviewing, problem-solving treatment, behavioral activation).
Comprehensive understanding of the interrelationship between medical and psychological systems and their impact on health.
Experience in documenting clinical activities in a comprehensive, clear, concise fashion on a same day basis.
Basic knowledge of psychopharmacology for common mental health disorders
Spanish, Vietnamese, Mandarin, Cantonese, Russian, Arabic, Korean

Responsibilities

Psychosocial Assessment: a. Screening and assessment of patients for common mental health and substance use disorders. Facilitate patient engagement and follow-up care. b. Provide patient education about common mental health and substance abuse disorders and the available treatment options.
Patient Services a. Systematically track treatment response and monitor patients (in person or by telephone or virtual visit) for changes in clinical symptoms and treatment side effects or complications. b. Manage collaborative care registry. c. Facilitate referrals for clinically indicated services outside of the organization (e.g., social services such as housing assistance, vocational rehabilitation, mental health specialty care, substance abuse treatment). d. Facilitate treatment plan changes for patients who are not improving as expected in consultation with the medical provider and the psychiatric consultant and who may need more intensive or more specialized mental health care. e.Systematically track treatment response and monitor patients (in person or by telephone or virtual visit) for changes in clinical symptoms and treatment side effects or complications.
Counseling: a. Provide brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other treatments as appropriate. b. Support the patient in their psychotropic medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment. c. Provide or facilitate in-clinic or outside referrals to evidence-based psychosocial treatments (e.g., problem-solving treatment or behavioral activation) as clinically indicated. d.Support the mental and associated physical health care needs of patients on an assigned patient caseload. Closely coordinate care with the patient’s continuity medical provider and, when appropriate, other mental health providers.
Departmental Functions: a.Participate in regularly scheduled (usually weekly) caseload consultation with the psychiatric consultant and communicate resulting treatment recommendations to the patient’s medical provider. Consultations will focus on patients new to the caseload and those who are not improving as expected under the current treatment plan. Case reviews may be conducted by telephone, video, or in person.
Documentation: a. Document patient progress and treatment recommendations in the electronic health record (EHR) and other required systems to be shared with medical providers, psychiatric consultant, and other treating providers. b. Track patient follow up and clinical outcomes using a registry. Document in-person and telehealth encounters in the registry and use the system to identify and re-engage patients. c.Develop and complete relapse prevention self-management plan with patients who have achieved their treatment goals and are soon to be discharged from the caseload.
Training: a.Provide effective teaching to all clinic learners including medical residents and care team members regarding behavioral health issues, evidence-based interventions, primary care integration, and patient engagement/communication strategies.
Miscellaneous: a. Attends conferences and seminars to maintain up-to-date knowledge of social work practices and principles. b.Participate in clinic meetings and relevant committees.