Clinical Social Worker, Care Coordinator - South Weymouth

About UsBrigham Health Harbor Medical Associates is a large multispecialty Ambulatory Practice with multiple locations across the South Shore.

We believe that patient care comes first! Our team of physicians, nurse practitioners, physician assistants, nurses, and support staff recognize the importance of prompt, expert, and compassionate care for patients whose needs span general health maintenance to treatment for complex medical problems.

Our physicians, who are on the staff at South Shore Hospital as well as Brigham and Women's Hospital, provide advanced care for patients with a broad range of medical conditions.

Integrated Care Management Program (iCMP) at Harbor Medical AssociatesiCMP at Harbor Medical Associates is an important initiative, based on an existing model at Brigham and Women's HealthCare (BWHC) and across the Mass General Brigham HealthCare System.

iCMP leverages nurse and social work care coordinators to establish, implement, monitor, and evaluate high-quality, cost-effective care plans for some of the sickest patients in our network.

The iCMP team collaborates with patients, their families, and Primary Care teams to develop care plans.The OpportunityWe are currently hiring a full-time, 40-hour Clinical Social Worker Care Coordinator to support patients at our Primary Care sites in the following locations : * 15 Corporate Park Drive, Pembroke, MA 02359* Stetson Medical Center, Suite 301 and Suite 400, 541 Main Street, South Weymouth, MA 02190* 56 New Driftway, Suite 101, Scituate, MA 02066* 6 Shipyard Drive, Suite 2A, Hingham, MA 02045As a hybrid opportunity, the position typically covers 1 day a week on-site but does require flexibility to go on-site more when needed (days can be flexible depending on the candidate's schedule) and remote coverage 4 days per week.

In addition, our team meets regularly at our South Weymouth office on-site for training, staff meetings, and team gatherings.

Working closely with high-risk patients, the Clinical Social Work Care Coordinator is responsible for establishing, implementing, monitoring, and evaluating high-quality, cost-effective care plans within the context of Harbor's developing Integrated Care Management Program (iCMP).

Responsibilities : * Reviews and assists in triaging new iCMP patients with the PCP, RN Care Coordinator, and other members of the iCMP team, as appropriate.

Completes comprehensive bio-psychosocial assessment of patients to evaluate clinical needs, including but not limited to mental health / psychiatric history / emotional issues / coping style, understanding of illness / adjustment / compliance, barriers to care, cultural issues, abuse and / or neglect and domestic violence, and substance abuse.

When abuse and / or neglect is / are suspected, the Clinical Social Worker files mandated reports as indicated by BWPO / Harbor Medical Associates policy and procedures.

Provides psycho-social assessment of families to determine family relationships / systems as they relate to the care of the patient, identifies family decision-makers and caregivers, and evaluates the family's understanding of illness and trajectory of care.

Identifies family coping style, resources, and cultural issues.* Working with the Care Team, develop a comprehensive care plan, appropriately utilizing the menu of services available to patients.

As indicated, provides direct and ongoing care management to select patients and / or refers to existing care management programs : insurance-based specialty case management programs, community resources, etc.

• Ensures the timely implementation of the care plan and communicates critical elements of the plan and trajectory of care to the patient, family, and members of the care team.
• Monitors the patient's progress and comprehensive care plan with the aid of internal and external utilization and quality data and guidelines, documents, and reports issues and system barriers.

Intervenes to ensure the plan of care and services provided are patient-focused, efficient, and cost-effective.* Establishes a consistent communication and reporting schedule for periodic contact with providers and patients to review patient status and progress toward goals.

• Evaluate, coordinate, manage, and document timely and relevant information in patient electronic medical records and the program's identified information technology tool (care management database) and communicate this information in a timely fashion* Identifies key barriers to care and the patient's ability to manage their health and wellness through initial and ongoing assessments.
• Communicate with other healthcare clinicians throughout the continuum about patient care, utilization, and follow-up plans, e.

g., inpatient facilities, ED Care Facilitators at BWHC, ED OBS Case Managers within the Care Progression Department at South Shore Hospital, inpatient Care Coordinators, post-acute case managers, social workers, pharmacists, etc.

Provides / completes necessary iCMP assessments upon discharge from an inpatient admission* Provides caregiver / family counseling or support to promote family / caregiver cohesiveness and ability to provide care to the patient.

Prepares patients and families for care transitions, including end-of-life care. Advocates on behalf of patients and families to gain access to services and resources.

Refers patients to other providers and iCMP team members, as needed* Coordinates family / team meetings when appropriate* May, on occasion, provide consultation to practice staff regarding patients who are not part of the high-risk program* 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 managing psychosocial and substance abuse issues in a high-risk, complex patient population and advocate for optimal outcomes* Collaborates with PCP and / or iCMP Manager and Medical Director regarding challenging patient situations, high-priority patients, and over / under utilization of services and patient compliance with program* Attends and presents in formal and informal case reviews, seminars, program meetings, and practice meetings* Participates in regular meetings with iCMP Manager and Medical Director to review performance, patient volume, projects, outside professional activities, and upcoming goals to achieveDue to the hybrid nature of the role, we ensure that our employees receive the required technology and training to be proficient and independently productive in all job responsibilities regardless of work location.

Employees are responsible for designating a workspace within the remote work location that is private, safe, ergonomic, and free from distractions for all hours worked.

Qualifications* MSW / LICSW or LCSW working toward LICSW* Five years experience in the field of psychiatry, substance abuse, trauma, and / or community mental health services preferred* Clinical experience, understanding of, and comfort working with patients of all ages who suffer complex medical and psychiatric problems;

ability to work with the families / caregivers of such patients, and the ability to help patients and families understand and access the resources required to support care* Strong understanding of psychiatric and family systems and ability to use this understanding to formulate succinct case summaries* Knowledge regarding end-of-life care* Demonstrated ability to be flexible and adapt to a complex, fast-paced medical environment