GENERAL SUMMARY/ OVERVIEW STATEMENT:
Given how much of individual and population health is related to the behaviors our patients chose, and the environment in which they live, we have decided that every healthcare team will have a dedicated social worker. 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 in making the changes they need to maximize their health. The social worker role is multifaceted and the following description further clarifies the role and responsibilities in concert with the social work ambulatory care job description.
PRINCIPAL DUTIES AND RESPONSIBILITES:
o Provide collaborative assessment, triage, stabilization and brief interventions around acute psychosocial/behavioral health issues that impact patients/families functioning and/or medical adherence
o Provide short- and long-term psychotherapy to patients as assessed. Treatment plan will reflect goals and plan of work being done. Billing will be done in accordance of the established guidelines.
o Provide recommendation and coordination of external and/or urgent psychiatric/social resources based on assessment and collaboration with patient/family.
o 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.
o Provide a care management approach around psychosocial/behavioral health needs using an evidence-based collaborative care management approach.
o Collaborates with the consulting psychiatrist, iCMP RN, Behavioral Health Support Specialist.
o Provide clinical assessment with patients around chronic disease and health behavior self-management obstacles.
o 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
o Provide interventions around behavioral change as part of the interdisciplinary team during office "warm handoff", shared medical appointments, and/or scheduled appointments.
o Provide follow-up and intervention with patient/family around psychosocial issues.
o Provide psychosocial care with patients who are at psychiatric risk, in collaboration with psychiatry/Team members/external resources, as indicated.
o Continuous develop of external professional relationships and knowledge of resources to further support and assist the needs of patients and their families.
Consultation and Education Role
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 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. Be the Behavioral Health Leader in the practice.
Provide consultation and education with the practice clinical team 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.
Practice process improvement efforts
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:
o Health literacy
o Abuse/Safety issues (Domestic violence, elder/child/disabled adult abuse and mandated reporting)
o Delivery of Behavioral Health Services
Provides care in scheduled one-on-one visits, in real-time warm handoffs from providers, by phone and by e-mail
Assist co-workers in their duties (within the limitations of training and scope of practice)
Cover other practices when their assigned clinical social worker is out, on vacation or a vacancy
All other duties as prescribed
Clinical experience, understanding of, and comfort working with patients of all ages who suffer complex medical and psychiatric problems; ability to work with the families of such patients, and ability to help patients and families understand and access the resources required to support care.
Ability to provide rapid clinical psychosocial assessments and brief, short or long term treatment/management with individuals, families, couples and/or groups.
Advanced crisis intervention/treatment/management skills; strong assessment and treatment skills.
Differential diagnosis and treatment with all modalities
Competence in abuse/neglect/violence, trauma, grief loss and bereavement
Cultural sensitivity and demonstrated competency in age specific behaviors
Knowledge of specific medical/psychiatric illnesses, procedures and treatments
Excellent clinical social work assessment and crisis intervention knowledge and skills
Strong understanding of psychiatric and family system problems, and ability to use this understanding to formulate succinct case summaries.
Knowledge of community agencies/resources. Ability to advocate/negotiate systems for/with patients and families.
Demonstrated ability to understand the role of social worker in a complex, fast-paced medical environment
Demonstrated ability to consult/teach
Demonstrated ability to communicate effective orally and in writing. Excellent interpersonal skills including negotiation skills necessary to collaborate within a multi-disciplinary team.
Tolerance for ambiguity; analytical skills and computer literacy
A sense of humor
Brigham And Women's Hospital