Transitional Housing Clinical Outreach Social Worker

Department Overview

The Clinical Outreach Social Worker (COSW) uses advanced clinical and/or healthcare operational subject matter expertise combined with systems and workflow knowledge to manage and assist in compassionate interventions to patients with complex psychosocial needs who discharge from OHSU Emergency Department and hospital. The COSW prioritizes clients with limited connections to outpatient services and frequent ED encounters. This population is growing in numbers, cost and complexity. This work requires unique skill set, flexibility and vast network of community partners to be able to effectively offer care. Job responsibilities include identifying enrollees, conducting needs assessments, identifying appropriate resources, and facilitating service engagement via face-to-face outreach and phone contact. Assessments and services are offered in the ED, hospital, on the streets and in homeless camps, in patient homes, outpatient clinics, and other community settings. The COSW coordinates treatment efforts with other OHSU departments, partners, community partners

and affiliates to advocate for client needs. Interventions aim to reduce unnecessary hospital and ED visits by improving access to medical care, substance use disorder treatment, mental health services and housing. While assisting clients in accessing services, the COSW identifies client strengths, models problem-solving skills, encourages mutual participation, and enhances self-advocacy abilities. The COSW participates in data collection for program evaluation purposes and partners with other team members to ensure effective implementation of services. The COSW’s values and care delivery

are consistent with the NASW code of ethics.

Specialty Addendum for this Transitional Housing COSW position: The TH COSW will provide specific direct service supports to patients in both the inpatient units and in the community to facilitate patients getting the appropriate level of care and resources. This Transitional Housing Clinical Outreach Social Worker will be supporting the Transitional care teams and TC motels, and will including hospital in-reach and in person community based outreach supports. This position will take lead on inpatient social work discharge planning and outreach care coordination for patients identified as participants in one of the OHSU Care Management Transitional care service lines (motels, RCP, AFH, ICF, etc).

This position is a flexible work position, which allows some remote work. Remote work at OHSU is a work arrangement under which an employee performs the duties and responsibilities of their position, and other authorized activities, from a non-OHSU location as part of their approved, regular work schedule. The Social Worker generally is expected to be in person at least half of their work time, depending on the expectations of their specific position. The social worker should have a private space at home, dedicated to work, and no Protected Health Information should be printed. Social Workers are expected to see patients in person, when at all possible, which may require coming to the hospital at short notice on a remote day. 

Function/Duties of Position

Intensive Clinical Management

• Care planning:
  • COSW assesses patients for psychosocial and transitional care needs and participates in developing patient-centered care plan. COSW assists patient in identifying goals and recognizing associated behavioral modifications. COSW acts as a liaison between patient and medical team when necessary and contributes clinical expertise to care plan, offers recommendations for diagnosis and treatment of mental health and addresses addictions issues when appropriate. For patients without established primary care, COSW facilitates linkage to clinics that best meet patient’s needs.
  • COSW may arrange appointments, complete intake paperwork, plan transportation options, accompany client to appointments, and support the patient and clinic staff during initial transition period. COSW often provide high level clinical care planning to outpatient community providers, and support both the patient and the clinics while during this engagement period. COSW support prescribers with having detailed understanding of patient’s care needs and care needs outside of the clinic or hospital setting.
• Coordination of care:
  • COSW facilitates cross-site communication between hospitals, clinics, and other community agencies. If patient returns to ED/hospital, SW serves as a source of knowledge about patient’s goals, care trajectory, post-discharge needs, and barriers to outpatient care.
  • COSW acts as a point of consistency between systems to improve patient experience. COSW are required to be effective in working within the outpatient, inpatient, emergency department an