Social Worker

Department Overview

OHSU Internal Medicine Clinic (IMC) is large (92 providers), academic primary care practice that serves patients from the Portland Metro area, and across the State of Oregon. Our clinic delivers traditional primary care to over 13,000 unique adults per year, in addition to housing consult and specialty clinics that care for over 2,000 unique patients per year. These services include Oregon's only academic HIV practice, Oregon's only academic Geriatrics practice, and a robust Addiction Medicine practice that supports inpatient and outpatient care across OHSU.

 

The Social Worker is responsible for supporting and coordinating the mental and physical health care of CoCM patients on an assigned patient caseload with the patient’s primary care provider and the CoCM psychiatric consultant. When appropriate, the Social Worker may also coordinate care with other internal and external mental health providers.

 

This position involves a high degree of clinical complexity and advanced level of skill in delivering evidence-

based interventions targeted to improve wellbeing and health for a large variety of patients with emotional and

behavioral concerns commonly seen in a primary care setting. The work includes screening and assessing

patients for common mental health and substance use disorders, providing education about these conditions,

discussing available treatment options, and facilitating patient engagement and follow-up care.

 

The Social Worker also is responsible for systematically tracking treatment, engagement, and response (via a registry) and for monitoring patients (either in person, by phone or virtual visit) for changes in clinical status and treatment side effects or complications. The Social Worker supports the patient in their management of their psychotropic medication, focusing on treatment adherence monitoring, side effects and effectiveness of treatment. Additionally, the Social Worker provides brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving therapy, motivational interviewing, and other treatments as appropriate. The role also involves participation in regular (weekly) caseload consultation with the psychiatric consultantand communication of resulting treatment recommendations to the patient’s continuity medical provider. The Social Worker performs duties with minimal supervision. Work is reviewed for adherence to procedures, regulations, standards and for overall effectiveness. The Social Worker position is expected to serve as an advocate for collaborative behavioral health within the physical health care setting.

Function/Duties of Position

Counseling:

• Provide brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other treatments as appropriate.
• Support the patient in their psychotropic medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment.
• Provide or facilitate in-clinic or outside referrals to evidence-based psychosocial treatments (e.g., problem-solving treatment or behavioral activation) as clinically indicated.
• Support the mental and associated physical health care needs of patients on an assigned patient caseload. Closely coordinate care with the patient’s continuity medical provider and, when appropriate, other mental health providers.

Psychosocial Assessment:

• Screening and assessment of patients for common mental health and substance use disorders. Facilitate patient engagement and follow- up care.
• Provide patient education about common mental health and substance abuse disorders and the available treatment options.

Patient Services

• Systematically track treatment response and monitor patients (in person or by telephone or virtual visit) for changes in clinical symptoms and treatment side effects or complications.
• Manage collaborative care registry.
• Facilitate referrals for clinically indicated services outside of the organization (e.g., social services such as housing assistance, vocational rehabilitation, mental health specialty care, substance abuse treatment).
• Facilitate treatment plan changes for patients who are not improving as expected in consultation with the medical provider and the psychiatric consultant and who may need more intensive or more specialized mental health care.
• Systematically track treatment response and monitor patients (in person or by telephone or virtual visit) for changes in clinical symptoms and treatment side effects or complications.

Documentation:

• Document p