Clinical Social Worker, LC or LICSW

Site: Newton-Wellesley Hospital

 

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

 

 

Job Summary

The Clinical Social Worker is an essential member of the interdisciplinary team reporting to the Care Coordination department and working under the direction of the Care Coordination Social Work Supervisor with support from Department leadership. The CSW is responsible for conducting bio-psychosocial assessments and creating treatment plans for select patients who require intervention and support. The social worker assumes clinical evaluation, intervention and planning for patients with complex psychosocial risks related to illness, homelessness, personal issues, frail elder status, safety concerns, financial difficulties, protective concerns, substance abuse and other emotional/mental health issues. The social worker’s interventions take into consideration the patient’s strengths, resources, insurance coverage, family system, and motivation for change to maximize the well-being and effective use of the health care system and community resources. The CSW coordinates with nurse case managers, physicians, nurses, rehabilitation specialists and other health team members inclusive of community partners to build a safe and effective transition plan for the patient to discharge from the acute facility. The social worker supports the mission of the hospital and participates in performance improvement activities, department initiatives, and various task forces or committees related to patient care.

The Clinical Social Worker will be crossed trained to enable ability to work in all inpatient units inclusive of: inpatient medical/surgical units, inpatient Pediatrics, Critical Care units, and the Emergency Department. At the discretion of the Supervisor/ Department leadership other departments may include Labor and Delivery, Post Partum care units, Newborn Nurseries, and the Special Care Nursery.

Clinical Practice/Job Responsibilities:
-Develops comprehensive bio-psychosocial assessments responsive to age appropriate and cultural needs and concerns. Employs a range of clinical interventions such as psychotherapy (individual, couples, families, and group), psychosocial counseling, crisis intervention, care coordination, information/resource provision, and referral and safety planning. Advocates on behalf of patients and families to gain access to services and resources.
-Provides mandated assessments when abuse is suspected (child, disabled adult, elder) and safety assessment when domestic violence is reported. Files reports as indicated. Offers clinical expertise and consultation to team members on an as needed basis.
-Supports adoptions, surrogacy, and high-risk post-partum cases that require SW support for safe discharge plans.
-Identifies patients’ psychosocial, financial, legal, housing, abuse/neglect issues, and psychiatric or substance use that effect patient care management. Collaborates with the interdisciplinary team to facilitate patient care process. Provides knowledge, guidance, and support to the medical and nursing staff regarding these patient care concerns.
-Completes all medical record documentation as per department/hospital policy including necessary paperwork in a timely and thorough manner.
-Coordinates family/team meetings, as needed and when appropriate. Provides psychosocial consultation on patient care planning and patient/family management and community resources. Implements psychosocial programs based on patient/family identified needs.
-Documents in the medical record per Hospital policy all patient/family communications including any discussion of financial and/or legal considerations. Communicates with compliance and legal outside council and legal teams to support safe discharge planning.
-Participates in quality assessment/improvement activities designed to evaluate the appropriateness and effectiveness of the service delivery system in which Care Coordination operates.
-Supporting that the patient and family understand consistent information along with team members regarding all aspects of care.
-Uses a patient centered/trauma informed care approach when working with high-risk patients to ensure equitable and supportive care is provided.
-Communicates and collaborates with the Social Work Supervisor/Team to ensure efficient and quality patient care and equitable caseloads.

Quality, Utilization Management: High Risk Psychosocial:
-Identifies patients who may require post discharge services utilizing high-risk screening criteria.
-In collaboration and/or consultation with the patient, the family, the attending and/or primary care physician, nursing staff, other appropriate clinical staff, third party payors and/or community-based care coordinators or other appropriate outside agencies; develops and oversees safe, effective, and efficient discharge plans.
-Provides ongoing oversight of the patient’s status in collaboration with a nurse case manager to determine the appropriate post-acute level of care and makes changes to the discharge plan as needed.
-Ensures the implementation of the discharge plan including facility/agency referrals and availability of services. This includes necessary Masshealth documents following standards of care.
-When appropriate, ensures that accurate and complete discharge paperwork is sent to post-acute service providers according to Hospital policies and procedures.
-In collaboration with external healthcare providers and primary care physicians; follow up as appropriate post discharge for those who meet high risk criteria.
-Maintains comprehensive knowledge of community resources.
-Offers information, education, and referrals to patients and families.
-Consults and advocates for patients during psychosocial emergencies.

Financial and Legal:
-Ensures third party payor approval for psychiatric inpatient placement.
-In collaboration with the RN CM and the UM team discusses appropriate utilization of resources.
-Understands patient’s general insurance coverage benefits and plans for discharge accordingly.
-Refers patients and families to appropriate resources or community agencies to apply for Mass Health, Medicare, Disability, etc.
-Initiates guardianship process/CMO/ and other legal concerns for inpatients needing guardianship for discharge planning or treatment options.
-Identifies external programs to assist patient with obtaining prescriptions, medical supplies and equipment, provide utilities i.e. heat and electricity if unable to afford, and to secure a primary care provider.

Organizational/Administrative Skills:
-Takes responsibility for own administrative duties, including timely and appropriate documentation in patient medical records, timely and accurate daily reporting of activities and Hospital’s scheduling systems, and accurate reporting of time worked.
-Provides clinical documentation including psychosocial assessment, progress notes, and billing compliance (if appropriate).
-Attends and participates in the rounds, department’s educational programs, staff meetings and other work-related groups.

Professional Conduct:
-Adheres to and fosters compliance with NASW Code of Ethics, and Department and Hospital clinical, quality, compliance and safety standards, policies, and procedures.
-Adheres to the hospitals policies related to dress code, time and attendance, and other code of conduct standards.
-Demonstrates and fosters an understanding and value of diversity, displays respects for others by utilizing inclusive behaviors, contributes to a harassment-free workplace; assists all patients, clients, residents, and employees.

Supervisory:
-Expected to mentor, precept, teach other social workers and support social work students.

Hospital-Wide Responsibility:
-Works within legal, regulatory, accreditation and ethical practice standards relevant to the position and as established by MGB; follows safe practices required for the position; complies with appropriate NWH/MGB policies and procedures; fulfills any training required by NWH and NASW board, as appropriate; brings potential matters of non-compliance to the attention of the Social Work Supervisor or other appropriate hospital staff.

Quality /Safety/Performance Improvement:
-Identifies, documents and reports quality of care issues in accordance with Hospital and departmental policies and procedures, including but not limited to occurrence screening, patient incidents and risk management issues.
-Contributes to the Department and Hospital's mission by serving on committees and participates in pertinent community activities.
-Participates in the Department and Hospital quality improvement initiatives.
-Provides patient care and services that are based on safe and approved standards of care.
-Carry out other functions as deemed necessary for Hospital compliance with State and Federal regulations and JCAHO accreditation.

Other Duties:
-Participates in special projects such as audits, policy and program development, and other such duties as directed.
-Participates and/or carries out other duties as assigned or requested.