The Clinical Social Worker is a key member of the iCMP (Integrated Care Management Program) team and the depression integration care team, providing and overseeing the provision of psychiatric, psychosocial and overall mental health services for high risk, medically complex patients.
The Clinical Social Worker is involved in assessment and triage of patients and families, to ensure provision of appropriate, timely, and effective evaluation. This initial clinical evaluation may be conducted by the social worker independently, or in collaboration with other members of the care team. The social worker collaborates with the care team and communicates relevant information.
The Clinical Social Worker may provide direct treatment/intervention to patients and families and/or may work with the treating clinicians in psychiatry, psychology, or other disciplines, within and outside of the system, helping to ensure that treatment is focused and effective.
Principle Duties and Responsibilities:
- Provides assessment of patients to evaluate mental health/psychiatric history/emotional issues/coping style, understanding of illness/adjustment/compliance, barriers to care, cultural issues, abuse, neglect and domestic violence. Working with the care team, prepares an intervention plan and disposition.
- Provides psychosocial assessment of families to: determine family relationships/systems as they relate to care of the patient; to identify family decision makers and caregivers; to identify family understanding of illness and trajectory of care; and to identify family coping style, family resources and cultural issues.
- Employs a range of clinical interventions such as brief individual, group, or family counseling. Provides caregiver/family counseling/support to promote family/caregiver cohesiveness to provide care to patient and prepare patient and families for care transitions, including end of life.
- Advocates on behalf of patients and families to gain access to services and resources such as financial and housing. Refers patients to providers as necessary.
- Provides brief transitional care management for patients with depression who are being discharged from an inpatient setting.
- Provides clinical support to the behavioral health support specialist (BS-level care extender on depression integration care team) through review of cases on a regular basis.
- Provides support and consultation to physician practices regarding depression management.
- Assesses when abuse is suspected and files mandated reports as indicated by guidelines.
- Works effectively as part of the care team, communicating regularly with the care manager and other members of the care team as needed.
- Coordinates family/team meetings as needed and when appropriate. Provides psychosocial consultation on patient care planning and patient/family management.
- Documents timely and relevant information in patient electronic medical record and care management system and communicates this information to the care team in a timely fashion.
- Acts as a resource to the care team and works, on a case by case basis, to coach and mentor on techniques and approaches to management of psychosocial issues in a high risk population and advocate for optimal outcomes.
- Presents and/or discusses clinical work in formal and informal case reviews and seminars as indicated.
- Performs other duties as assigned.