The Primary Care Social Worker performs those accountabilities relevant to addressing the psychosocial concerns of patients and families. Through advanced practice skills, mobilizes health, psychosocial and economic resources. Creates optimal outcomes for the patient and family by managing complex psychosocial and economic co-morbidities. Collaborates and partners with patients as an integral member of the care team and acts as a liaison and advocate between the patient, family, healthcare providers, services and community agencies.
- Experience working with medically and socially complex patients.
- Previous experience in care management, disease management and/or case management
- Behavioral/mental health experience
- Experience in motivational interviewing
- Electronic Medical Record experience (Epic preferred)
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Ability to sit or stand for extended periods and to move quickly between tasks.
- Ability to hear and converse on the phone and in person.
- Ability to see fine print and to use the computer.
- Ability to perform fine motor tasks, such as when working with instruments, taking blood pressures and performing other patient care tasks, writing, computer or phone tasks.
- Ability to safely lift up to 20 pounds and to push/pull up to 100 pounds when working with equipment, pushing wheelchairs or assisting with patient handling tasks.
- Ability to bend/twist and crouch when performing various job tasks.
- Ability to work with and to wear appropriate Personal Protective Equipment when working with bloodborne pathogens or other chemicals.
- Ability to wear a respirator/mask.
- Conducts assessments to identify psychosocial, financial, or legal issues and concerns of patients and their families.
- Maintains and facilitates open communication with the patient, family, and the healthcare team.
- Is available to participate in clinic office visits with patients when needed.
- Coordinates family conferences in collaboration with physicians and other health care providers to enable patient and family/significant others to work on identified issues.
- Improves patient and/or family knowledge and understanding of their medical diagnoses to maximize benefits of the medical plan of care and enhance patient/family functioning.
- Coordinates information and referrals for financial and community resources and skillfully links patients and families/significant others to the appropriate resources.
- Maintains confidentiality and complies with professional ethics according to professional and corporate standards.
- Develops and updates plans of care that are patient-centric with goals that are clearly defined.
Maintains a working knowledge of relevant medical/legal issues that impact patient care, e.g., advance directives, power of attorney, guardianships, and reporting of abuse.
- Assists patients and families/significant others with completing Advanced Directives, Healthcare Power of Attorney or Declaration of Physicians (Living Will).
- Assures strong collegial working relationships with internal and external healthcare organizations and community resources.
- Participates in the monitoring of quality and utilization metrics and participates in improvement efforts to refine the delivery of care to maximize clinical, quality, and fiscal outcomes.
- Adheres to department productivity standards.
- Records documentation for all social work activities in the electronic medical record in a timely and thorough manner.
- Performs other duties as required.