Licensed Clinical Social Worker

Cottage Health•Santa Barbara, CA

18d

About The Position

Using evidenced based guidelines and best practice as a foundation, the Licensed Clinical Social Worker is responsible for performing bio-psycho-social assessments, care coordination and clinical interventions, program development & discharge planning. Effectively intervenes with medically and psychosocially complex patients, while demonstrating the ability to understand complex dynamics related to the clinical situation. Medical Social Worker ensures that the patient and family experience adhere to Cottage Health Patient First Philosophy and is consistent with the Mission and Vision of our health care organization. Responsibilities This is not an exhaustive statement of duties, responsibilities, or requirements. Employees will be required to perform any job, with related instruction given by their supervisor, subject to reasonable accommodation. Psychosocial Assessment: Assess the patient?s social situation, dynamics and capacity to cope with the illness, treatment and hospitalization. Coordinate with multidisciplinary team members, including outside agencies or systems and act as liaison between medical team and the patient and family system. Identify and use differential diagnoses as appropriate for the psychological, emotional or social barriers that interfere with medical treatment, positive outcomes, or discharge plan in various adult and pediatric settings. Clarify and address conflicts that might arise between medical team and the patient and/or family system, may include identifying legal guardian and family spokesperson or agent for Advanced Directive compliance. Assist with establishing Advanced Directive and Power of Attorney. Act as advocate for patients, families and Cottage Health. Provide medical crisis counseling and emotional support to patients, families and staff around psychosocial stressors, adjustment to illness, end-of-life, grief, and bereavement issues. Consult and conduct assessment and make appropriate referrals on suspected child, dependent adult or elder abuse, domestic violence, substance abuse issues and mental illness cases. Act as liaison between patient/family and schools, work sites. Discuss cases as appropriate with relevant stakeholders (such as patient, physicians, other providers and payers) to best align social work case management plan, level of care and funding resources. Provides a high level of clinical expertise, critical thinking and problem solving skills to situations in order to achieve desired outcomes. Maintain timely and accurate records of all activities relating to the assessment process, documenting activities as appropriate in the medical record. (30%) Discharge Planning: On admission, participates in the coordination and development of a discharge plan. In conjunction with the healthcare team, patient and family stakeholders identifies likely post-discharge needs. Provides appropriate information, education and choice, making referrals as appropriate to implement the discharge plan (i.e. charity applications, Family Assistance Fund, community resources, home healthcare, institutional placements, financial assistance, DME equipment needs and/or alternative/specialized care settings). Resource linkage for uninsured and/or underinsured patients, displaced families, immigrants and refugees who need medication and aftercare placements in shelters/transitional housing, sober living, SNF, substance abuse residential programs, etc. Use multidisciplinary collaboration, hospital programs and resources, community resources, home care services, institutional placements, financial assistance and mental health counseling to plan and coordinate patient apos;s discharge as needed. Facilitates the transfer of patients to other care facilities as appropriate. Intervene with behaviorally challenged patients and/or patients unwilling to leave hospital to facilitate a safe/timely discharge plan. Maintain timely and accurate records of all activities relating to discharge planning, documenting activities as appropriate in the medical record. (30%) Resource Coordination: Ascertain healthcare benefits utilizing both internal and external resources as appropriate to coordinate necessary and appropriate care, while appropriately preserving the healthcare benefits of the beneficiary. Link uninsured/underinsured patients to available medical insurance coverage or charity resources. Identifies and coordinates appropriate resources to address basic needs of patient and family i.e (meal coupons, breast pumps, car seats, transportation vouchers, clothing, housing, medical supplies, social services, humanitarian visas and charity services, etc). Identify and refer situations requiring immediate intervention to the attending physician, risk management, department director and/or physician advisor as appropriate. Refer cases not meeting criteria (including situations involving the timely provision of services) to the department director and/or physician advisor as appropriate. Maintain timely and accurate records of all activities relating to the resource coordination process, documenting activities as appropriate in the medical record. (25%) Quality Assurance: Participates in the improvement of organizational performance through quality assurance and performance improvement activities. Participates in the tools, measurement and continuous improvement of quality, productivity, value and efficacy of clinical social work case management functions. Participates in care planning activities, rounds, committee meetings and other activities as appropriate, and documents assessment identifying obstacles to discharge planning as well as confirming patient meets criteria for acute hospitalization. Supports system-wide development, analysis and implementation of process improvement initiatives. Reports suspected and/or emerging patterns and trends (i.e. increase in self-pay patients, substance abuse/homeless, difficult to place, mentally ill and/or the vulnerable elderly patients from ED and Med Surg floors, perinatal drug abuse and child/adult abuse and neglect). Cooperates fully in all risk management activities and investigations. Obtain continuing education units necessary to maintain LCSW current and in good standing and be up to date with Evidence Based Practices. Improving throughput through Shared Governance Projects, staff consultations, and interdepartmental policy development. (5%) Education: Clinical Social Worker conducts assessment of patient and families understanding of the illness/diagnosis and provides psychoeducation as appropriate. Discuss and educate the patient/family on the care delivery process: provision of services, information and the legal document including but not limited to Advanced Directives, POLST; healthcare providers and resources, issues related to funding, and areas of patient choice and accountability. Explains the plan of care and treatments within the context of the patient?s/family?s values, and in a language understood by the patient/family. Takes a leadership role in teaching, training or providing in-service education to both social work and non-social work staff within the organization as well as externally to other organizations or groups. As appropriate, assists in coordinating an educational plan with the interdisciplinary healthcare team. (5%) Leadership and Collaboration: Provides consultation, support and ongoing education as needed to help promote and manage a value-oriented experience for persons served. Serves as a consultant for clinical social work issues and as coach/mentor to colleagues, students and other staff. Facilitate and lead specialized patient groups, participates in, departmental meetings, care planning activities, rounds, committee meetings and other activities as appropriate. Demonstrates a continuing effort to improve the quality of his/her performance to better the organization (such as continuing education/professional development and/or through participation/membership with appropriate professional organizations). (5%) Provides a high level of clinical expertise, critical thinking and problem solving skills to situations in order to achieve desired outcomes. Develops population-specific clinical expertise in area of practice. Provides clinical supervision to social work colleagues looking to obtain a clinical social work license. Represents the discipline of social work on hospital, community or other committees of interest. Takes a leadership role in teaching, training or providing in-service education to both social work and non-social work staff within the organization as well as externally to other organizations or groups. (5%)

Requirements

Master'sin Social Work (MSW) degree from a Council onSocial Work Education (CSWE) accredited School of Social Work
Current California Clinical Social Work License (LCSW)required upon hire.
Demonstrate the ability to identify, assess, counsel andeffectively intervene with medically and psychosocially complex cases.
Strong interpersonal skills that reflect positive attitudeand sense of commitment to patients, colleagues and community.
Demonstrates professionalism, communication, and compassionwith regard for human dignity.
Excellent verbal and written communicationskills that reflect a positive attitude and a sense of commitment to ourpatients, work associates and community.
Excellent organizational skills.
Ability to workindependently.

Nice To Haves

California Children Services (CCS) paneling is requiredwithin six months of hire.

Responsibilities

Assess the patient?s social situation, dynamics and capacity to cope with the illness, treatment and hospitalization.
Coordinate with multidisciplinary team members, including outside agencies or systems and act as liaison between medical team and the patient and family system.
Identify and use differential diagnoses as appropriate for the psychological, emotional or social barriers that interfere with medical treatment, positive outcomes, or discharge plan in various adult and pediatric settings.
Clarify and address conflicts that might arise between medical team and the patient and/or family system, may include identifying legal guardian and family spokesperson or agent for Advanced Directive compliance.
Assist with establishing Advanced Directive and Power of Attorney.
Act as advocate for patients, families and Cottage Health.
Provide medical crisis counseling and emotional support to patients, families and staff around psychosocial stressors, adjustment to illness, end-of-life, grief, and bereavement issues.
Consult and conduct assessment and make appropriate referrals on suspected child, dependent adult or elder abuse, domestic violence, substance abuse issues and mental illness cases.
Act as liaison between patient/family and schools, work sites.
Discuss cases as appropriate with relevant stakeholders (such as patient, physicians, other providers and payers) to best align social work case management plan, level of care and funding resources.
Provides a high level of clinical expertise, critical thinking and problem solving skills to situations in order to achieve desired outcomes.
Maintain timely and accurate records of all activities relating to the assessment process, documenting activities as appropriate in the medical record.
On admission, participates in the coordination and development of a discharge plan.
In conjunction with the healthcare team, patient and family stakeholders identifies likely post-discharge needs.
Provides appropriate information, education and choice, making referrals as appropriate to implement the discharge plan (i.e. charity applications, Family Assistance Fund, community resources, home healthcare, institutional placements, financial assistance, DME equipment needs and/or alternative/specialized care settings).
Resource linkage for uninsured and/or underinsured patients, displaced families, immigrants and refugees who need medication and aftercare placements in shelters/transitional housing, sober living, SNF, substance abuse residential programs, etc.
Use multidisciplinary collaboration, hospital programs and resources, community resources, home care services, institutional placements, financial assistance and mental health counseling to plan and coordinate patient apos;s discharge as needed.
Facilitates the transfer of patients to other care facilities as appropriate.
Intervene with behaviorally challenged patients and/or patients unwilling to leave hospital to facilitate a safe/timely discharge plan.
Maintain timely and accurate records of all activities relating to discharge planning, documenting activities as appropriate in the medical record.
Ascertain healthcare benefits utilizing both internal and external resources as appropriate to coordinate necessary and appropriate care, while appropriately preserving the healthcare benefits of the beneficiary.
Link uninsured/underinsured patients to available medical insurance coverage or charity resources.
Identifies and coordinates appropriate resources to address basic needs of patient and family i.e (meal coupons, breast pumps, car seats, transportation vouchers, clothing, housing, medical supplies, social services, humanitarian visas and charity services, etc).
Identify and refer situations requiring immediate intervention to the attending physician, risk management, department director and/or physician advisor as appropriate.
Refer cases not meeting criteria (including situations involving the timely provision of services) to the department director and/or physician advisor as appropriate.
Maintain timely and accurate records of all activities relating to the resource coordination process, documenting activities as appropriate in the medical record.
Participates in the improvement of organizational performance through quality assurance and performance improvement activities.
Participates in the tools, measurement and continuous improvement of quality, productivity, value and efficacy of clinical social work case management functions.
Participates in care planning activities, rounds, committee meetings and other activities as appropriate, and documents assessment identifying obstacles to discharge planning as well as confirming patient meets criteria for acute hospitalization.
Supports system-wide development, analysis and implementation of process improvement initiatives.
Reports suspected and/or emerging patterns and trends (i.e. increase in self-pay patients, substance abuse/homeless, difficult to place, mentally ill and/or the vulnerable elderly patients from ED and Med Surg floors, perinatal drug abuse and child/adult abuse and neglect).
Cooperates fully in all risk management activities and investigations.
Obtain continuing education units necessary to maintain LCSW current and in good standing and be up to date with Evidence Based Practices.
Improving throughput through Shared Governance Projects, staff consultations, and interdepartmental policy development.
Clinical Social Worker conducts assessment of patient and families understanding of the illness/diagnosis and provides psychoeducation as appropriate.
Discuss and educate the patient/family on the care delivery process: provision of services, information and the legal document including but not limited to Advanced Directives, POLST; healthcare providers and resources, issues related to funding, and areas of patient choice and accountability.
Explains the plan of care and treatments within the context of the patient?s/family?s values, and in a language understood by the patient/family.
Takes a leadership role in teaching, training or providing in-service education to both social work and non-social work staff within the organization as well as externally to other organizations or groups.
As appropriate, assists in coordinating an educational plan with the interdisciplinary healthcare team.
Provides consultation, support and ongoing education as needed to help promote and manage a value-oriented experience for persons served.
Serves as a consultant for clinical social work issues and as coach/mentor to colleagues, students and other staff.
Facilitate and lead specialized patient groups, participates in, departmental meetings, care planning activities, rounds, committee meetings and other activities as appropriate.
Demonstrates a continuing effort to improve the quality of his/her performance to better the organization (such as continuing education/professional development and/or through participation/membership with appropriate professional organizations).
Provides a high level of clinical expertise, critical thinking and problem solving skills to situations in order to achieve desired outcomes.
Develops population-specific clinical expertise in area of practice.
Provides clinical supervision to social work colleagues looking to obtain a clinical social work license.
Represents the discipline of social work on hospital, community or other committees of interest.
Takes a leadership role in teaching, training or providing in-service education to both social work and non-social work staff within the organization as well as externally to other organizations or groups.