Social Worker - Primary Care

Housecall Providers•Portland, OR

2d•$44 - $54•Hybrid

About The Position

The Social Worker is responsible for delivery of social work services to patients, including psychosocial evaluations, ongoing counseling, casework services, coordination of referrals, transitions, and potentially palliative care and bereavement services. These patients may have advanced illnesses and often have other complex medical/psychosocial/addiction issues. The Social Worker provides support and care for patients in various settings including: all types of patients’ home settings, assisted living residences, shelters, hospitals, emergency departments, skilled nursing facilities, clinics, and specialty settings. NOTE: This position will cover NE Portland and St. John's area.

Requirements

Master’s degree in social work from an accredited college
Current Oregon LCSW, LMSW or CSWA license
Minimum 1 year work experience in geriatrics, home health, hospice, hospital, primary care/specialty care clinic or other community based mental health or outreach social work
Valid driver’s license, acceptable driving record, and automobile liability coverage or access to an insured vehicle
CPR certification at hire or within 6 months in position
Practice within the scope of license where applicable, and as required by law and regulation.
Ability to assess psychosocial needs, establish and implement a social work plan of care, triage urgent and crisis situations, and stay focused
Ability to be sympathetic to a patient, family or caregivers needs, and be able to deal with people in various states of pain, trauma and tragedy
For those working with advanced illness patients, employees must feel comfortable supporting patients at the end of their life; including facilitating, evaluating and coaching advanced care planning conversations performed by AIC Team or other CO programs
Ability to exercise sound clinical judgment, independent analysis, critical thinking skills and knowledge of medical and behavioral health conditions when identifying clients’ multidisciplinary needs, developing health goals and communicating with providers
Must be a clear, timely and compassionate communicator and be able to maintain healthy boundaries
Ability in case management and counseling with frail and complex patients
Ability to communicate effectively with diverse staff and patients, their families and caregivers
Able to establish therapeutic relationships with patients, families, caregivers and staff using effective communication
Excellent interpersonal skills
Ability to adhere to organizational standards, policies and procedures
Ability to work both independently and collaboratively
Ability to work under pressure to meet deadlines
Ability to take initiative and utilize innovative techniques and ingenuity
Ability to interact with various departments throughout the organization
Ability to work flexible hours, if needed
Must be organized and have the ability to plan, prioritize and coordinate multiple projects or tasks
Must have general computer skills and a working knowledge of Electronic Medical Records systems, MS office, Outlook, and the internet
Ability to work in an environment with diverse individuals and groups
Ability to learn, focus, understand, and evaluate information and determine appropriate actions
Ability to accept direction and feedback, as well as tolerate and manage stress
Ability to see, read, hear, and speak clearly for at least 6 hours/day
Ability push, pull, stand, sit, and perform repetitive finger and wrist movement to for at least 3-6 hours/day
Ability to lift, carry, pinch small objects, walk, bend, and climb stairs for up to 3 hours/day
Ability to operate a motor vehicle in all kinds of weather conditions

Nice To Haves

Experience dealing with substance use disorders, care coordination and needs assessment for high-risk populations

Responsibilities

Conduct comprehensive psychosocial assessments and make appropriate referrals to community resources as well as provides education to patients and families regarding community resources, benefits and entitlements.
Collaborate with clinical and support staff regarding patient/family/caregiver issues.
Conduct patient and family counseling and education considering family system/dynamics and coping methods to all age groups and make appropriate referrals to other community resources if indicated.
Help patient and family/caregiver develop coping strategies to manage declining physical health, and emotional or spiritual needs.
Closely partner with patient providers and interdisciplinary care team across the continuum to facilitate care that meets the individual’s personal needs, values, and preferences.
Provide short-term crisis intervention and assume active role of advocate for family.
Assist clinicians and clinical teams with management of transitions of care when patients are moving from one setting to another, including (but not limited to) from place of residence to hospital or nursing home and back, assisting with placement as needed.
Provide direct patient care support in a variety of settings.
For those working closely with advanced illness patients, the Social Worker will utilize palliative care principles, trauma informed care, motivational interviewing and case management strategies.
Participate as a member of interdisciplinary care team assisting with establishing and implementation of psychosocial care plan in patients with serious, complex and/or chronic illness which could include partnering with Primary Care, Hospice or AIC team members.
Assist patients and family with advance care planning which includes discussions about goals of care/treatment, answering general questions about power-of-attorney documentation, the POLST form and the Oregon Advanced Healthcare Directive Form.
Communicate and coordinate with other providers to ensure care is coordinated and consistent with patient’s goals of care, including AD/POLST.
Assist with establishment of POA-HC (power of attorney for health care) and with establishment of end-of-life care plans as needed.
Provide education to patients, family members, caregivers and Housecall Providers’ staff regarding mental health issues, grief, resiliency, hospice services, community resources, benefits and entitlements.
Provide consultation on ethical issues that arise for HCP staff.
Conduct mental status exams (e.g., MMSE, SLUMS, MoCa) as requested by Providers.
Provide advocacy for patients and families with various community agencies, care facilities and other institutions as needed.
Assist clinicians with organization and/or facilitation of care conferences for assessment, education or conflict management.

Benefits

medical, dental, vision, life, AD&D, and disability insurance
health savings account
flexible spending account(s)
lifestyle spending account
employee assistance program
wellness program
discounts
multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.)
strong retirement plan with employer contributions
PTO
Paid State Sick Time
paid holidays
volunteer time
jury duty
bereavement leave