Description

Provides a wide range of clinical social work services in a primary care or home health setting, including support and consultation to care team in managing patients. Evaluate psychosocial assets and deficits for the purpose of enabling the pt to maintain the greatest level of independence. Coordinates with others to establish a plan of care. Provides short term counseling, teaching and brokering with other resources for care giving needs.

The Social Worker Mental Health Specialty case management position will act as a clinical resource to the Mental Health Specialty clinics by being an active member of the care team. Participate in clinic huddles and partner with care team members to identify patients with severe persistent mental illness (SPMI) who would benefit from additional support to manage their mental health conditions and psychosocial needs. Social Worker case managers provide virtual and in person care in individual and group modalities. Social Worker case manager role offers a hybrid of therapeutic intervention and community connection support. Provides care for both acute and chronic mental health needs/conditions.

• Provide appropriate social work interventions to all age patients and their families including but not limited to psychosocial assessment, brief individual or family, advocacy, linkage, referral, group work, case coordination, and long-term care planning and placement.
• Consultation and coordination with multidisciplinary team of care professionals and primary care site medical/nursery staff, to include family conferences, care conferences, team meetings and etc.
• Assesses patient and family needs for care and communicates with other health care providers appropriately. Collects data relevant to visit with ongoing assessment throughout the duration of care. Evaluate psychosocial assets and deficits for the purpose of enabling the pt to maintain the greatest level of independence.
• Evaluates patients/family needs through timely assessment, communication and observation. Modifies plan of care through assessement based upon patient/care systems response.