To develop and maintain a comprehensive program of services for behavioral health patients and and their families aids in the adjustment to living with a chronic socioeconomic and and life-threatening illness. This includes advocacy, community education, acute counseling/therapy, research, program development, evaluation, and any other assigned responsibility relating to social work. Works with and under the direction of primary care providers and staff psychiatrist.
Master’s Degree in Social Work from an accredited School of Social Work, or Master’s Degree in Professional Counseling, or equivolent.
State licensure as: Licensed Social Worker (LCSW)Licensed Marriage and Family Therapist Current AHA BLS certificationTwo years experience in the health care field or 3000 hours of post masters work in supervised clinical social worker practiceESSENTIAL FUNCTIONS
Support the mental and physical health care of patients on an assigned patient caseload. Closely coordinate care with the patient s medical provider and, when appropriate, other mental health providers.
Screen and assess patients for common mental health and substance abuse disorders. Facilitate patient engagement and follow-up care.
Provide patient education about common mental health and substance abuse disorders and the available treatment options.
Systematically track treatment response and monitor patients (in person or by telehealth) for changes in clinical symptoms and treatment side effects or complications.
Support psychotropic medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment.
Provide brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other treatments as appropriate.
Provide or facilitate in-clinic or outside referrals to evidence-based psychosocial treatments (e.g. problem-solving treatment or behavioral activation) as clinically indicated.
Participate in regularly scheduled (usually weekly) caseload consultation with the psychiatric consultant and communicate resulting treatment recommendations to the patient s medical provider. Consultations will focus on patients new to the caseload and those who are not improving as expected under the current treatment plan. Case reviews may be conducted by telehealth, video, or in person.
Track patient follow up and clinical outcomes using a registry. Document in-person and telehealth encounters in the registry and use the system to identify and re-engage patients. Registry functions can be accomplished through an EHR build, on a spreadsheet used in conjunction with an EHR, or can be built into a stand-alone clinical management tracking system that may or may not be linked to an EHR.
Document patient progress and treatment recommendations in EHR and other required systems so as to be shared with medical providers, psychiatric consultant, and other treating providers.
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
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).
Develop and complete relapse prevention self-management plan with patients who have achieved their treatment goals and are soon to be discharged from the caseload. .