Complex Care Team Clinical Social Worker Lead (LICSW)

Mass General Brigham•Boston, MA

2d•Hybrid

About The Position

The Complex Care Team Clinical Social Worker is an integral member of the Complex Care Management Team, collaborating to reduce length of stay and readmissions due to psychosocial factors. They work in conjunction with unit-based teams and interface with interdisciplinary healthcare teams. This role provides and oversees psychosocial care for patients with complex psychosocial risk factors, such as safety concerns, protective services needs, and homelessness. The Clinical Social Worker delivers clinical services addressing psychosocial, environmental, age-specific, and cultural issues to optimize well-being and the effective use of healthcare and community resources, ensuring appropriate post-discharge services. This is achieved through rapid clinical biopsychosocial assessments, intervention, and treatment in collaboration with other social workers, identifying high-risk psychosocial factors impacting health status, and educating care teams on their influence on medical care. The role involves collaboration and consultation with other hospital and community disciplines, and participation in task forces and committees. The position reports to the Senior Nurse Director of Case Management, with clinical peer support from the Director of Social Work.

Requirements

Master's Degree in Social Work required.
Licensed Independent Clinical Social Worker [LICSW - State License] required.
5-7 years of clinical social work experience required.
Expert depth of specialized clinical diagnoses and interventions.
Routinely sought out by team members for consultation on complex cases and conflict resolution.
Expert clinical assessment and diagnostic skills; acts as role model and mentors other staff.
Advanced utilization of clinical skills and interventions; consistently contributes to training and education of staff.
Highest degree of leadership, flexibility, communication, independence, and teamwork.
Expected to provide significant contributions to education, training, and clinical supervision.
Leads or actively participates in clinical practice inquiries, teaching, projects, or research demonstrating expertise and depth of knowledge of social work practice and skills.
May participate in the recruitment, onboarding, and retention processes.
Completed LICSW requirements.
Leads department/service initiatives; participates in initiatives at an Enterprise and Professional Association level.
Knowledge of specific medical and psychiatric illnesses, procedures and treatments, related medications (i.e., psychotropic, chemotherapy, etc.), acuity versus chronicity, effect on normal growth and development specific to service.
Ability to rapidly conduct and develop comprehensive biopsychosocial assessments responsive to age-appropriate patient/family needs and concerns.
Ability to provide short term or long-term treatment/management of individuals, families, couples, and groups.
Exceptional organizational skills and ability to prioritize effectively to complete work in a timely way in the acute care environment.
Strong assessment, crisis intervention, and treatment skills.
Ability to communicate effectively orally and in writing.
Strong interpersonal skills enabling effective collaboration.
Competence in assessing and intervening in abuse/neglect, violence, trauma, grief, loss, and bereavement.
Competence working with people from diverse racial, ethnic, and socioeconomic backgrounds.
Demonstrates ability to understand the role of a clinical social worker in a healthcare setting, highly motivated and capable of performing effectively in a complex, fast-paced environment.
High degree of flexibility, independence, ability to prioritize multiple acute concerns, advanced management skills, strong sense of initiative and perseverance to carry through to completion of tasks.
Develops an effective working relationship with patient/family to engage, collaborate, advocate, and problem-solve to enhance their functioning.
Develops effective working relationships with interdisciplinary colleagues, multiple rotating care teams, internal collaterals, and external collateral agencies to engage, collaborate, advocate, and problem-solve to optimize a plan of care, reduce length of stay, and avoid readmission.
Demonstrates competency in age-specific behaviors, cultural issues, and the impact of illness on patients/families.
Provides consultation, information, and professional support to interdisciplinary team members and social work colleagues.
Shares knowledge of community agencies and resources.
Ability to navigate complex systems with patients/families and to effectively advocate on their behalf.
Demonstrates initiative and leadership to drive the psychosocial plan of care in response to patient care needs.
Documents in medical record according to Departmental policies and procedures.
Maintains patient/family confidentiality in accordance with HIPAA and MGH policies.
Ability to consult and teach.

Responsibilities

Rapidly performs clinical biopsychosocial assessments, including evaluation of social history, current functioning, mental health, substance use, psychiatric history, support system, coping styles, understanding of illness, barriers to care, cultural issues, abuse/neglect/safety concerns, and intimate partner violence.
Provides psychosocial assessment of families to determine family relationships/systems as they relate to patient care, identifying decision-makers, caregivers, understanding of illness, coping styles, resources, and cultural considerations.
Formulates diagnostic impressions, recommendations, and plans, collaborating with the care team to optimize the plan of care and disposition to reduce length of stay and readmission.
Manages consultation requests in a fast-paced environment, prioritizing needs relative to patient acuity and barriers to safe discharge.
Provides mandated assessments when abuse is suspected (child, disabled adult, elder) and specialized safety assessments when violence is suspected, filing mandated reports as indicated.
Provides consultation and guidance to mandated reporters of other disciplines.
Employs a range of clinical interventions including psychotherapy (individual, couples, families, and group), short-term counseling, crisis intervention, safety planning, care coordination, complementary therapies, information, and referral.
Advocates on behalf of patients and families to gain access to services and resources.
Works effectively as a vital collaborator with the interdisciplinary care team.
Provides psychosocial consultation on patient/family care and management.
Facilitates the appropriate and efficient use of Hospital resources.
Collaborates with internal collaterals (e.g., Office of Patient Relations, Office of General Counsel, Optimum Care, Child Protection Team, HAVEN, Police and Security, International Office, Office of Decedent Affairs) and external agencies to optimize the plan of care.
Identifies patients’ psychosocial, financial, legal, psychiatric or substance use discharge barriers and collaborates with the team to facilitate safe transitions in care.
Coordinates family team meetings as needed and when appropriate in collaboration with the interdisciplinary team.
Assesses patient/family learning needs, styles, and readiness, and educates them based on the treatment plan, identifying barriers, diversity and equity issues, and learning styles.
Provides education and consultation to interdisciplinary health care providers, social work staff, students, and the community on psychosocial issues.
Presents cases at weekly Complex/Leadership meetings.
Facilitates, leads, or participates in Departmental and Hospital committees as necessary.
Collaborates and consults with patient, families, and providers within the Hospital and community to develop and implement patient care plans.
Refers to and collaborates with Departmental programs, Hospital programs, outside agencies, facilities, payors, and other relevant community resources.
Completes timely clinical documentation including psychosocial assessment, post-acute referrals, and progress notes.
Adheres to the profession’s clinical standards and Code of Ethics.
Adheres to the Department and Hospital standards, policies, and procedures.
Promotes Departmental and Hospital public relations.
Provides risk management.
Adheres to Departmental and Hospital quality/safety standards.
Participates in individual clinical supervision as appropriate to professional development.
Is responsible for own professional development.
Attends continuing education and professional activities related to job responsibilities and career goals.
Keeps current with social work and health care developments pertinent to the job and profession.
Complies with licensure requirements.
Uses data to define baseline issues and measure progress.
Oversees collaboration and education among all disciplines and outside stakeholders to enhance patient care.