PSS Social Worker

POSITION PURPOSE:

The Patient Support Specialist (PSS) Social Worker will play a crucial role within both the Patient Support Services (PSS) and Comprehensive Care Clinic teams. The primary objective of this position is to assess and address patients' behavioral health, substance use, and social needs through counseling, crisis interventions, and referrals, with the goal of improving overall health outcomes and supporting patients in achieving or maintaining their health goals. The position also supports patients in accessing resources related to housing, transportation, and other social determinants of health.

MAJOR POSITION RESPONSIBILITIES AND FUNCTIONS:

• Evaluate patients' needs for behavioral health services, substance use counseling, housing, and transportation, and make appropriate referrals and linkages.
• Conduct individual, couple, and family counseling and psychotherapy sessions.
• Deliver crisis interventions, offering immediate support in challenging situations.
• Provide support services using social determinants of health, harm-reduction, and trauma-informed care principles.
• Collaborate with PSS and other clinic team members, including the Behavioral Health team, to ensure patients receive comprehensive support and care.
• Stay informed about local, state, and federal services available to patients.
• Address patients’ socioeconomic needs, assist with referrals, linkages, monitoring, and tracking outcomes as part of the PSS team.
• Serves as liaison between HIV counseling and testing team and medical clinic, ensuring new patients are enrolled in care smoothly and promptly.
• Perform home visits and other field outreach as needed on a case-by-case basis.
• Conduct a comprehensive Social Determinants of Health assessment through a cooperative, interactive face-to-face interview within five working days of patient contact, considering age, gender, cultural, and linguistic factors. The assessment will gather information on the client's social, emotional, behavioral, mental, spiritual, and environmental status, as well as family support systems, coping strategies, strengths, weaknesses, and adjustment to illness.
• Develop an intervention plan within five days, incorporating information from the Social Determinants of Health assessment and considering the patient’s behavioral, psychological, developmental, and physiological strengths and limitations.
• Provide patient counseling and intervention sessions, including targeted educational interventions that focus on risk reduction strategies. Additionally, offer support for behavioral health referrals as needed, with the goal of preventing high-risk behaviors and enhancing patient adherence.
• Offer periodic training to clinic staff.
• Provide services to patients who are not yet enrolled in PSS or clinic-based programs.
• Provide guidance and direction to the ROS/HS to ensure timely follow-up with patients and accurate completion of documentation.
• Attend meetings and training sessions to enhance skills and stay current on nursing best practices and other related issues. Ensure compliance with continuing education requirements.
• Participate in Quality Improvement (QI) meetings, presentations, and other required QI activities. Monitor and analyze trends related to non-medical quality improvement (QI) indicators, such as the effectiveness of risk reduction interventions.
• Document patient interactions and progress and contributes to program evaluation.
• Actively participates in case conferences.
• Complete all patient documentation within 24 hours of service delivery.
• Adhere to HIPAA guidelines regarding patient care and confidentiality.
• Perform additional duties as assigned by the supervisor, as needed to support departmental goals and operations.

POSITION REQUIREMENTS AND QUALIFICATIONS:

• Master’s degree in social work, Counseling, Psychology, or a related field from an accredited program.
• At least two years of relevant work experience with patients in public health, community services, or medical settings.
• Experience conducting patient or client assessments.
• Experience working with vulnerable populations (e.g., individuals with addiction disorders, mental illness, homelessness, or those who inject drugs).
• Strong interpersonal skills.
• Ability to advocate for patients effectively.
• Ability to deliver care in an ethical, non-judgmental, culturally competent, and non-discriminatory manner.
• Willingness and ability to learn how to navigate the complex housing support systems within Los Angeles County.
• Comfortable performing field-based work when necessary.