Complex Care Team Clinical Social Worker Lead (LICSW)

Site: The General Hospital Corporation

 

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Job Summary

The Complex Care Team Clinical Social Worker is an integral member of the Complex Care Management Team. They are a vital collaborator on the care team to help reduce length of stay and readmission due to psychosocial factors. In conjunction with the unit-based teams they support and interface with the interdisciplinary health care teams. The Complex Care Team Clinical Social Worker provides and oversees the provision of psychosocial care for patients who have co-morbidities that drive evaluation, intervention and planning for patients with complex psychosocial risk (e.g., safety concerns, protective services, homelessness, etc.) They provide 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, to ensure appropriate and high-quality services are provided after discharge at the right site of care, all while supporting clinical excellence for discharge plans. This is accomplished by conducting rapid clinical biopsychosocial assessments, providing intervention and treatment as indicated and in collaboration with any involved social worker on the care team; identifying high risk psychosocial factors that impact health status and helping care teams understand the influence of those factors on the course of medical care.

The Complex Care Team Clinical Social Worker collaborates with and provides social work consultation to other disciplines within the Hospital and community and participates in Departmental, Hospital, and community task forces and committees.

The Complex Care Team Clinical Social Worker reports directly to the Senior Nurse Director of Case Management with clinical peer support from the Director of Social Work.

Clinical Practice:

Rapidly performs clinical biopsychosocial assessments to include evaluation of social history, current functioning, mental health, substance use, psychiatric history, support system, coping styles, understanding of illness, barriers to care, cultural issues, abuse/neglect/safety concerns, intimate partner violence.

Provides psychosocial assessment of families to determine family relationships/systems as they relate to care of the patient. Identifies family decision makers and caregivers, family understanding of illness and trajectory of care and coping styles, family resources and cultural considerations.

Formulates diagnostic impressions, recommendations, and plan. Collaborates with care team to develop and optimize plan of care and disposition to reduce length of stay and readmission.

Works in a very fast-paced, dynamic, demanding environment, receiving consults throughout the day to evaluate a broad range of issues and concerns acutely. Manages consultation requests by understanding and prioritizing needs relative to patient acuity and barriers to safe discharge.

Consult reasons include but are not limited to: adjustment to new diagnosis/illness/injury, end of life and complex bereavement needs, safety concerns including child, disabled, elder abuse, neglect and financial exploitation, sexual assault, intimate partner violence, trauma, mental health and psychiatric concerns, complex relationship and family dynamics, coping, advanced directive/guardianship and custody concerns, limited supports and accessing resources.

Provides mandated assessments when abuse is suspected (child, disabled adult, elder) and specialized safety assessment when violence is suspected. Files mandated reports as indicated. Provides consultation and guidance to mandated reporters of other disciplines when they must file.

Employs a range of clinical interventions such as psychotherapy (individual, couples, families, and group), short-term counseling, crisis intervention, safety planning, care coordination, complementary therapies, information and referral. Advocates on behalf of patients and families to gain access to services and resources.

Works effectively as a vital collaborator with the interdisciplinary care team. Provides psychosocial consultation on patient/family care and management. Facilitates the appropriate and efficient use of Hospital resources.

Collaborates with many interna