Social Worker- Primary Care- West Roxbury/ Hyde Park

Mass General Brigham•Hyde Park, IL

7d•Hybrid

About The Position

The Clinical Social Worker (LICSW) is a key member of the interdisciplinary team who provides and oversees the provision of behavioral health and psychosocial care for patients and families who receive their medical care in one of the BWH primary care practices. The social worker will engage collaboratively with patients, families and the interdisciplinary healthcare team to address psychosocial barriers to care, lead efforts around management of psychiatric disorders for the team’s patients, and coach patients and families with options and support for change, to maximize their overall physical/behavioral health. The Clinical Social worker conducts bio-psychosocial assessments, provides intervention and treatment (therapy) as indicated. Identifies high risk psychosocial factors of patients/families that impacts their ability to make change and helps other providers/interdisciplinary team members understand the influence of those factors upon the course of their care. Provides clinical services to patients/families that address psychosocial, environmental, age-specific and cultural issues to maximize emotional, social and physical wellbeing and the effective use of health care and community resources. Collaborates with and provides clinical support to other programs to optimize patient wellbeing.

Requirements

Master’s of Social Work Degree from an accredited program required.
Current Massachusetts Licensed Independent Clinical Social Worker (LICSW) required.
Clinical Experience in a medical setting 2-3 years required.

Nice To Haves

Previous clinical social work experience in a hospital and/or Primary Care setting preferred.
Bilingual (English/Spanish) preferred.
Ability to maintain motivation to achieve goals while dealing with challenges.
Excellent organizational and time management skills.
Excellent crisis intervention skills.
Ability to maintain confidentiality and secure sensitive information.
Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.

Responsibilities

Provide collaborative assessment, triage, stabilization and brief interventions around acute psychosocial/behavioral health issues that impact patients/families functioning and overall health.
Provide Short- and long-term therapy to patients who want to engage in ongoing clinical interventions to help promote change and improvement in patients overall rating of their mood and life circumstances.
Participate in established billing practices while adhering to established guidelines.
Provide recommendation and coordination of external and/or urgent psychiatric/social resources based on assessment and collaboration with patient/family.
Provides risk assessment and intervention in conjunction as part of the interdisciplinary team with emphasis on harm reduction, and when necessary emergency services, and coordination with appropriate resources.
Provide a care management approach around psychosocial/behavioral health needs using an evidence-based collaborative care management approach.
Providers behavioral health leadership in practice.
Provide appropriate modality for patient self-reported improvement in their mood as evidenced by regular PHQ-9, GAD7 and other evidence-based tools.
Participates in formal and informal clinical case reviews, clinical supervision, educational seminars and research projects.
Provide clinical assessment with patients around behavioral health symptoms that are impacting daily functioning.
Provide health behavior interventions that include, but not limited to, health action plans, utilizing change interventions; motivational techniques and problem solving that addresses obstacles to goals, and supports and increases patients and their family’s self-efficacy of health behaviors.
Provide follow-up and intervention with patient/family around psychosocial issues that impact a patient’s medical/functional recovery outcome.
Provide psychosocial care with patients who are at psychiatric risk, in collaboration with psychiatry/team members/external resources, as indicated.
Continuous develop of external professional relationships and knowledge of resources to further support and assist the needs of patients and their families.
Reach out to facilities where a patient was admitted for behavioral health care and be the primary contact and liaison for the PC practice/provider.
Conduct Post Discharge calls to patient being released from a BH inpatient setting.
Collaborates with the different team disciplines around awareness, education, and recommendations to address psychosocial, mental health and motivational issues that impact the patient/family chronic disease, no show/cancellation of appointments, medication adherence, and provide direct clinical work as indicated.
Provide education opportunities to the practice about clinical methods/techniques that further support health behavior changes in patients; motivation interviewing, problem-solving techniques, etc.
Provide education and awareness of behavioral health/psychiatric conditions and issues that impact provision of care and health outcomes.
Provide consultation and education to practice staff and team partners (CC and iCMP) around psychosocial issues that arise in their role, and provide direct clinical counseling as indicated.
Participate in the education of students and residents around their awareness, knowledge and understanding of psychosocial/behavioral health issues and their impact on health behaviors and outcomes.
Develop groups to meet the needs of the practice and share/teach to social workers in other primary care clinics.
The Social Worker will stay up to date and demonstrate Social Work Best Practices.
Demonstrates active, ongoing commitment to professional growth and development of self and creates an environment conducive to the professional growth of others.
Co-Lead the implementation of collaborative, evidence-based models of care for psychosocial needs and mental health/behavioral health for the team; depression, anxiety, other as identified.
Participate in process improvement groups.
Other improvement efforts as appropriate within scope of practice.
Leads the development and continuous improvement of practice level efforts related to: Health inequities/disparities, Health literacy, Abuse/Safety issues (Domestic violence, elder/child/disabled adult abuse and mandated reporting), Delivery of services to hard to reach populations with the practice.
Provides care in scheduled one-on-one visits and in real time with Warm Handoffs.
Provides clinical documentation including psychosocial assessment, progress notes, and billing compliance (if appropriate) within 48 hours of the encounter.
Will receive requests for services/input, triage and reply using face to face contact, Outlook, Epic in-basket within 48 hours.
Provide coverage for other social workers in Primary Care when they are out of the office and to help coverage practice social work vacancies.
Assist co-workers in their duties (within the limitations of training and scope of practice).
Consult with Manager and/or Clinical Educator as needed.
Attends and participates in Staff Meetings and interdisciplinary meetings/rounds.
All other duties as prescribed.
Adheres to and fosters compliance with NASW Code of Ethics, and Department and Hospital clinical, quality, compliance and safety standards, policies and procedures.
As level of clinical skill increase and time allows there are opportunities to mentor, precept, teach social workers and social work residents.
Meets Department productivity and standards. Responsible for completing tasks for billable encounters that follow guidelines set by the insurance companies and JAHCO.
Works within legal, regulatory, accreditation and ethical practice standards relevant to the position and as established by BWH/Partners; follows safe practices required for the position; complies with appropriate BWH and MGB policies and procedures; fulfills any training required by BWH and/or MGB, as appropriate; brings potential matters of non-compliance to the attention of the manager or other appropriate hospital staff.